Self-paced Courses Enrollment Form

Print this form and mail or fax to the Friday Center for Continuing Education at the address below.
Please type or print clearly in black ink.

Social Security number: __________ - _____ - _________
You are strongly encouraged to provide your Social Security number (SSN) here so that the University may more easily verify your information and process any financial aid and/or scholarship application you may submit. Submission of your SSN on this form is voluntary, however. If you submit your SSN on this form, the University will use it to create a unique University identifier to verify records and match documents associated with your application, enrollment, and other educational records. Please note that, if you enroll at the University, you will be required to provide your SSN in order for the University to comply with federal and state reporting requirements.

PID number (for UNC-Chapel Hill students only) __ __ __ __ - __ __ __ __ __

Name_______________________________________________________________
(First, Middle, Last)

Current Mailing Address:

Street address_______________________________________________________

City_____________________________________ State________ Zip___________

County (if NC) or Country______________________________

Permanent Mailing Address:

Street address_______________________________________________________

City_____________________________________ State_________ Zip___________

County (if NC) or Country__________________________

Home phone # (______ )_____________________________

Daytime phone # (_______)___________________________

E-mail address (please print clearly): ________________________________________

Gender: M / F    Birth date:______/______/______

ETHNIC ORIGIN:
__Asian or Pacific Islander     __Black, Non-Hispanic     __Hispanic   
__American Indian/ Alaskan native    __Other     __White, Non-Hispanic

RESIDENCY (check all that apply):
____I request to be classified as a North Carolina resident for tuition purposes. I understand that until a final determination is made and I am notified in writing, I am considered to be a nonresident for tuition purposes. (All applicants who claim NC residency must complete the Residency Status Form.)
____I am a nonresident for tuition purposes.

Citizenship (check one):  
___US Citizen (U)    ___Resident alien--"green card" holder (R)
___Nonresident alien (N)

HIGHEST LEVEL OF EDUCATION COMPLETED (check one):   
___High school diploma/GED    ___Associate degree    ___Bachelor's degree
___Master's degree    ___Doctorate degree    ___I am a high school student (year_______)

STATUS (check only those that apply):
___I am not a degree-seeking student.

___I am a UNC-Chapel Hill degree-seeking student. Dean's signature giving you permission to enroll:
______________________________________________ date:______________

___I am a degree-seeking student at another college or university. Name of school: _______________________________________________________________
Dean's signature giving you permission to enroll:
______________________________________________ date:______________

___I qualify for the military tuition benefit. (If so, you must be a nonresident of North Carolina on active duty, stationed in North Carolina at the time of your application. A separate North Carolina residency form will be sent to you.)

___I am taking this course to meet high school graduation requirements.

___I am seeking teacher certification or certification renewal.

___I am taking a credit course on a not-for-credit basis.

___I am taking this course for no letter grade, on a credit-only basis (available only for NCSU courses).

___I am taking this course to regain academic eligibility at (name of institution):
_______________________________________________________________

___I am a UNC-Chapel Hill student and have received credit for the course for which I am applying.

TYPE OF ENROLLMENT (check one):
___New course enrollment
___Credit by examination
___Transfer to (new course):______________ from (original course):__________
___Re-enrollment
___Tutorial Independent Study course (Special form required. See Tutorial Independent Study.)

Are you attempting to meet a deadline? ___Yes (give date)____/____/____    No___
See Time Limits. If you are trying to complete your course in less than twelve weeks, you will need to request an exception from the Appeals Committee.

COURSE INFORMATION (indicate courses you wish to take):
You may enroll in up to two courses at one time.

METHOD OF PAYMENT: 
(Please do not send cash, and do not send payment for books with this application.)

___Check enclosed. Person/Organization paying for this enrollment if not student:

________________________________________________________________
To avoid delay, if you are enrolling in two courses please write a separate check for each course. Make checks payable to the Friday Center for Continuing Education (Federal ID# 56-6001393). There will be a $25.00 charge on all returned checks.

__VISA  __MasterCard  #__ __ __ __-__ __ __ __-__ __ __ __-__ __ __ __ Expiration date___/___/___
Please note: We only accept VISA or MasterCard.

Cardholder (please print)____________________________________________

Cardholder's signature______________________________________________

Refunds of tuition will not be made after an enrollment of 30 days.

OTHER INFORMATION (check all that apply):
Where did you learn about Self-paced Courses?

IMPORTANT: Please read the following and then sign and date below:

RESIDENCY STATUS--You are considered to be a nonresident for tuition purposes until you have submitted a North Carolina Residency Status Form and received notification of your residency status.
REFUND--You must withdraw within 30 days of enrollment in order to receive a partial refund.
TIME LIMITS--The minimum time permitted to complete a three-credit-hour course is twelve weeks from the time we receive your first assignment.

I HEREBY CERTIFY THAT:

• I have read the rules stated on this Web site..
• I will adhere to all rules and standards, particularly those described in the Honor Code and Time Limits sections.
• I have made sure that the courses I wish to take are appropriate to my degree program.
• I have satisfied all prerequisites.
• A copy, including a facsimile copy, of my signature hereto shall be given the same effect as my original signature.

Student's signature___________________________________ Date_______________