Continuing Education

Application for Credit Registration

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Company/District:   WestEd Eisenhower Regional Consortium

Course Location:  Online Course

Course:  MEDUC6630 Earth Systems Science Course for Elementary School Teachers

Credits:  3     Cost:  $30.00

Name: ___________________________________________   ___ M   ___ F
                (Last / First / M)

Date of Birth ____/____/____  Social Security Number:______________________
                         (Mo. / Day / Yr.)

Mailing Address: ________________________________________________________

City: ____________________ State: _____ Zipcode: ___________

Telephone: (____) ____________________________

Semester you are applying for:   Spring

Application Status:   Transfer

The answers I have given in this application are complete and accurate to the best of my knowledge.

Signed: _____________________________________ Date: ____________________

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