2017 APPLICATION FORM FOR 100 SCHOLARS U G Berkeley Summer Sessions ...
2017 APPLICATION FORM FOR 100 SCHOLARS
U
Berkeley Summer Sessions | 1995 University Ave., Suite 130, Berkeley, CA 94704 | Fax: 510.664.9825 | E-mail: summer@berkeley.edu
PERSONAL INFORMATION
G
* Required Field
Last Name* (Family Name/Surname)
as appears in passport
First Name* (Given Name)
Middle Name
as appears in passport
as appears in passport
Sex* (Gender):
Birthdate* (MM-DD-YYYY)
Male
Female
Decline to state
Street Address*
City*
State/Province
Zip/Postal Code*
E-mail Address*
COURSE SELECTION
Subject*
Telephone Number*
PAYMENT INFORMATION
Fax/Alternate Number
STUDENT INFORMATION
* Required Field
Catalog
Number*
Class
Number*
100
12345
Session*
C
Grading
Option*
Units*
2
$920
* Required Field
What is your current Visa Status?*
Permanent Resident
Other
Are you currently an enrolled college student?
COURSE 4 COURSE 3 COURSE 2 COURSE 1
Ex.
Country*
No
Yes
Name of the school you currently attend
Have you received the equivalent of a U.S. Baccalaureate (BA/BS)
Degree?*
Yes
No
Have you applied for admission to UC Berkeley for Fall 2017?
Yes
No
Have you attended UC Berkeley before?*
Yes
No
Name of the school you currently teach at
Name of the school district
* Required Field
Maximum $3,840 + Registration Fee $ 380.00 + Document Management Fee $55.00 = YOUR TOTAL FEES DUE* $ 435.00
The Total of All Tuition from above* $ _____________
I understand that Berkeley Summer Sessions is allowing me to register using this paper application due to circumstances that have prevented me from using
the online application form. I agree to establish my CalNet ID and pay my fees in full via Calcentral ().I understand that my
transcript will be blocked, late fees will be assessed and the University may refer my account to a commercial collections agency should I fail to pay my fees.
Signature*
STUDENT SIGNATURE
Date*
* Required Field
I understand that the admission to Berkeley Summer Sessions is conditional on compliance with University policies, and may be revoked at the discretion of Summer Sessions
in accordance with the Code of Student Conduct (sa.berkeley.edu/code-of-conduct). I also agree to the rules regarding fees, refunds, and enrollment changes published on
the Summer Sessions website (summer.berkeley.edu), including, but not limited to, the $100 NON-REFUNDABLE portion of the fees.
Signature*
Date*
EMERGENCY CONTACT INFORMATION
Berkeley Summer Sessions | 1995 University Ave., Suite 130, Berkeley, CA 94704 | Fax: 510.664.9825 | E-mail: summer@berkeley.edu
PERSONAL INFORMATION
* Required Field
Student Name*
Student E-mail*
EMERGENCY CONTACT 1
Student Phone Number*
* Required Field
First Name*
Last Name*
Relationship*
E-mail*
Phone Number*
Alternate Phone Number
EMERGENCY CONTACT 2
* Required Field
First Name*
Last Name*
Relationship*
E-mail*
Phone Number*
Alternate Phone Number
EMERGENCY CONTACT INFORMATION RELEASE AUTHORIZATION
Under the Federal Family Education Rights and Privacy Act of 1974 and provisions of state law relating to public records disclosure, the University of California Policies Applying
to the Disclosure of Information from Student Records and the Berkeley Campus' implementation of that policy assure that student information is protected.
In case of an emergency, it may be necessary to access and release your information protected by the
aforementioned law and policies. By checking this box, you are giving your written consent to access and
release relevant information to appropriate parties connected with the emergency.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- sponsored tuition at uc berkeley extension
- undergraduate students fall 2017 fact sheet university of california
- 2017 18 berkeley academic calendar office of the registrar
- establishing residency for tuition purposes
- 2017 application form for 100 scholars u g berkeley summer sessions
- establishing residency for tuition purposes berkeley graduate division
- berkeley student health insurance plan ship 2017 18 plan year waiver
- 2017 annual report berkeley student cooperative
- the 2017 2018 university of california rankings roundup
- uc berkeley campus human rights center fellowship 2017 deadline
Related searches
- completed job application form examples
- application form for business license
- application form for ministry position
- indian pan card application form for nri
- application form for volunteers
- medical marijuana application form for missouri
- dmv application form for permit
- uc berkeley summer tuition
- application form for canada visa
- application form for unemployment benefits
- application form for university
- application form for canadian citizenship