Registration Form for Independent Learning Courses

REGISTRATION FORM FOR INDEPENDENT LEARNING COURSES
Name:
Social Security No.:
Address (Street, Apt., Box):
City:		State:	Zipcode:
Telephone:
Email Address:
Are you an AU student? :			What is your major? :
What year in college are you? :			What is your graduation date? :
Are you a U.S. Citizen?			If not, what country?
Are you currently in an Independent Learning course?
Are you currently under academic suspension?			If yes, for what duration?
Explain how you have met the prerequisites (if any) for this course :
How did you hear about our Independent Learning Program?
Signature :				Date :
COURSE 1
Course Number :				Extended Option Graded Option (AU Students Only)
Course Title :
Number of Semester Hours :
COURSE 2
Course Number :				Extended Option Graded Option (AU Students Only)
Course Title :
Number of Semester Hours :
DEANS APPROVAL FOR AU STUDENTS (Au students must obtain their Dean's and academic advisor's approval to enroll)
Signature of Advisor:
Signature of Dean :
Date :
FEES
Tuition (@ $140 per semester hour) :
Registration Fee (@ $57 per course)
Texts / Materials Cost :
Sales Tax (Alabama residents only -- 8%):
Foreign Air Mail if Overseas ($60) :
PAYMENT
Payment Method (Circle One) : Visa \| Mastercard \| Check \| Money Order
Card Number :
Cardholder Name :
Expiration Date :
Signature :
SUBMITTING APPLICATION
Mail Application to:	Distance Learning Office
	Petrie Annex
	Auburn University, AL 36849-5611
FOR MORE INFORMATION
Phone: (334) 844-3114	Fax: (334) 844-3125		E-Mail: audl@auburn.edu