Name (last, first, middle)

---

Current Address

---

City                                                                 State                                                                Zip Code

---

Home phone (     )                                           Office phone (     )                                           Email:

---

Check here if this is a new address or telephone number: ___

---

Course Information

CODE	COURSE	CREDIT HRS.	INT / EXT / SEMINAR

Tuition Payment Information                  Please read carefully

TUITION: Number of Credit hours    x     $          per credit hour               =	$
REGISTRATION FEE: (If applicable for initial registration)                               +	$
Check here if you want CTU Book Store to ship textbooks to you. (   )
TOTAL BOOK FEES: (If applicable, check with book service.)                       +	$
TOTAL PAYMENT: (To be remitted with registration or write "On Contract".)	$

I understand that I am responsible to meet the financial obligations incurred for the courses for which I registered.
I understand that certain fees incurred (registration, books, etc.) are nonrefundable.
I hereby register for the courses listed above.

Student signature____________________________________________     Date_______________________________