Print this form and fax to:
California State University-San Bernardino
College of Extended Learning
Fax   909-880-5907


Name of Student:__________________________________________

Address:__________________________________________________

City, State, Zip:_________________________________________

Phone_________________________Fax_________________________

e-mail address:____________________________________________

Social Security Number:____________________________________

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 Check the appropriate box.
    Basic Math/Pre Algebra EECR 1258
    Elementary Algebra/Algebra l EECR 1257
    Intermediate Algebra/Algebra ll EECR 1259
    Plane Geometry EECR 1289


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Visa, Mastercard

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(if different from name above)

Card Number:______________________________________________

Card Expiration Date:__________________

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