UC Berkeley Extension
Enrollment Form
If you are enrolling in an online course, read important information at www.unex.berkeley.edu/info/enroll_online.php.

Print out form, complete and
Fax to: (510) 642-0374. Be sure to include your credit card information.
Or Mail to: Dept. B, UC Berkeley Extension, 1995 University Ave., Suite 110, Berkeley, CA 94704-7000.

PERSONAL INFORMATION
Priority Code:
If you have received a catalog, brochure, or other publication from UC Berkeley Extension, this 5-character code can be found on the mailing label, (example: 102AX)

For my permanent student record, this is my home business address
Last Name:
First Name:
Middle Initial:
Company/Agency:
(for business address only)
Address:
City:
State:
Zip:
Daytime Phone: *
Evening Phone: *
Fax:
Title/Occupation:
E-mail: *

*UC Berkeley Extension will use the contact information you provide to notify you of changes in your class schedule and other Extension information. If you are enrolling in an online course, you are required to participate in chat rooms and message boards specific to the course. The e-mail address and/or online identity you use when entering chat rooms, or as you post on message boards, will be visible to all other participants. By enrolling in an Extension online course, you authorize the disclosure of your e-mail address and/or online identity for this purpose.

Social Security Number:
The University is required by federal law to report your Social Security Number and other pertinent information to the Internal Revenue Service pursuant to the reporting requirements imposed by the Taxpayer Relief Act of 1997. Social Security Number disclosure is mandatory. This notification is provided to you as required by the Federal Privacy Act of 1974.

COURSE INFORMATION

Course Number 1
Course Title:
Starting Date:
Location (city):
EDP Number:
Fee:
(less discount* if applicable):

Course Number 2
Course Title:
Location (city):
Starting Date:
EDP Number:
Fee:
(less discount* if applicable):

DISCOUNTS
A copy of your California Alumni Association membership card must be included to receive a discount
Member number:
Membership expiration:

PAYMENT INFORMATION
Card Type: Visa MasterCard American Express Diners Club
Card number:
Expiration Date: Month / Year
Name of cardholder:
Authorizing Signature:
Credit card holder’s billing address if different from student address above:
Name:
Billing Address:
City:
State:
Zip:

To pay by check, make check payable to UC Regents.

For companies/agencies paying by purchase order: fax purchase order and this form to (510) 642-3910.

Confirmation of enrollment will be sent upon receipt of payment. Please allow 5 business days to receive you enrollment confirmation via U.S. mail. You may phone (510) 642-4111 earlier to confirm your enrollment. If your class is full, you will be placed on a waiting list and notified if space becomes available. Please note: Not receiving enrollment confirmation before the start of your course is not justification for seeking a refund.

Please refer to refund policy and deadlines, and course cancellation policy and other registration and enrollment information.

The University of California, in accordance with applicable federal and state law and University policy, prohibits discrimination, including harassment, on the basis of race, color, national origin, religion, sex, physical or mental disability, medical condition (cancer-related or genetic characteristics), ancestry, marital status, age, sexual orientation, citizenship, or status as a covered veteran. This nondiscrimination policy covers admission, access, and treatment in University programs and activities. Equity Standards & Compliance (ESC) responds to questions about prohibited forms of discrimination, or will refer you to a more appropriate campus resource (see the ESC website at http://equity.chance.berkeley.edu ). ESC may be contacted at (510) 642-2795 or esc@berkeley.edu. Specific questions about sexual/racial harassment may be directed to Nancy Chu, Title IX/VI Compliance Officer in ESC.