Syracuse University University College Noncredit Course Registration Form A Mail your completed registration form to: University College Bursar/Registration Operations, 700 University Ave., Room 103, Syracuse, NY 13244-2530 or fax it to 315-443-3255. The registration deadline is: Tuesday, May 26, 2015 Allow 5-7 business days for processing mail or fax registrations. Last Name ■ First Name Initial Social Security Number (optional) SU ID Number Date of Birth MO. DAY YR. M-Male F-Female Check if name change Student Level Program/ Plan: UCNC Registration Status SWKNC/SWKNC Permanent Address ■ ■ 1- New student to Syracuse University - OR Enter Number 2- Returning Syracuse University student City State Zip Code Check if this is a new address Permanent Phone: Cell Phone: Business Telephone: ■ ■ ■ Check if new Check if new Personal E-mail: (required for online course) Dept. Prefix & Course No. Business E-mail: Class Dates FNC 200 U001 Check if new Term May 28, 2015 Title Summer 2015 Class No. Understanding EMDR Therapy 74239 Fees $25 Payment Information — if fee is required B PARTICIPANT ACKNOWLEDGEMENT (must be signed for registration to take place): For SU/UC Office Use Only: I understand that non-credit classes do not count toward any degree requirements at SU and that no academic credit will be earned in this program. I also understand that SU is only responsible to retain noncredit records for 7 years, and it is the participant’s responsibility to retain this information for future reference. I understand that the University fees and charges are due before confirmation of registration in this program, and I agree to pay to the University, all fees and charges during my entire attendance at the University. Signature of person fi responsible if minor (parent /guardian) Signature of Participant Date Total Amount Due Total Amount Paid Registration Method: Date Paid ❏ In Person ❏ Faxed ❏ Mailed ❏ Delivered Indicate payment type and date here_ Your initials Date Date For questions regarding the presentation contact: Tracey Musarra Marchese at [email protected]. Print name and address of signature immediately above For questions regarding completing the registration form contact: University College at 315-443-4135 or [email protected]. Self-pay Participant – Payment-in-full enclosed ❏ CHECK or MONEY ORDER (Payable to Syracuse University) CHECK or MONEY ORDER AMOUNT ❏ VISA AMOUNT: ❏ MasterCard ❏ Discover Card number House # of cardholder (REQUIRED) Cardholder’s signature ❏ American Express Exp. Date Zipcode of cardholder (REQUIRED) Cardholder’s name Print as it appears on the card 5/15