SAN JOSE STATE UNIVERSITY SPECIAL SESSION - DOC by IEtTF70j

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									                                        Application for Personalized Preparation Program
                                           Designated Subjects Teaching and Supervision Program
                                                 Fall Registration 09/01/2011 – 12/21/2011
                                                     Santa Clara Local Education Agency
                                                              Lee and Susan Clark
Please Print – or type                                                                                               Ethnic Origin
                                                                                                                      1. America Indian/ Alaskan Native

Social Security Number _____ _____ ________ OR SJSU ID # __________________                                           2. Black Non -Hispanic
                                                                                                                      3. Chicano, Mexican-      For Office Use:
Full Legal Name ____________________ ________________ __________________                                                  American
                                                                                                                                                Confirmation:
                           Last                First        Middle                                                    4. Other Hispanic
Street Address __________________________________________________________                                             5. Asian
                   Number               Street                                                                        6. Pacific Islander       In Computer:
City _____________________________State ___________________ Zip __________                                            7. White Non-Hispanic
                                                                                                                      8. All other responses
                                                                                                                                                Faxed:
Telephone (Daytime or Work) ( ______) ___________ Evening ( _____) __________                                         9. No response
                                                                                                                      F. Filipino
E-MAIL ADDRESS:___________________________________________                                                                                      Paid:
                                                (print clearly)
Date of Birth ______________________                     ______ Male                       ____ Female

Have you previously registered for classes at San Jose State University? ______ Name (if different) ___________________

          1. (See http://www.leeclark.org/Health%20Course.htm for specific instructions)
          Please stipulate Payee as: Santa Clara Local Education Agency!
          2. Mail application and three separate fees (check or money order) to:
              (See http://www.leeclark.org/Health%20Course.htm for specific instructions)
                      Lee W. Clark
                      Sunnyvale Adult and Community Education
                      591 West Fremont Avenue (Room 6)
                      Sunnyvale, CA 94087

Note: You will receive an email confirming your registration!

     For Office Use               ADD           DATE      2010        DATE        DEPARTMENT          COURSE          SECTION       UNITS          FEES
                                                                                                      NUMBER


         4     9    8 0 6                  09/01/10          to   12/21/10          EDUC          380 Health            01            01          $159

(*Course code numbers, etc. will be completed by the office.)

TERM 2114



         Last                           First                      Middle

                             Amount Paid $________
METHODS OF PAYMENT

   Personal Check or Money Order may be submitted with the application.
   Please put your name on the face of the money order.

If my payment by check is not paid by the bank for any reason, I am responsible for all course fees and penalties.




Signature                                                                       Date

								
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