Contract Credit Registration Form

College of Extended Education
Student & Business Services Building, Suite 211 (open Mon.-Fri., 8 a.m.-5 p.m.)
Cal Poly Humboldt • 1 Harpst St. • Arcata, CA 95521-8299
phone   707-826-3731 • e-mail   extended@humboldt.edu

NOTE: Please do not use this form to submit Extended Education, OLLI, Open University or Graduate Continuous Enrollment registrations.


Student Information

= Required field

Select your gender identity:*

Have you ever been enrolled at Cal Poly Humboldt?

Have you completed a Bachelor's Degree or higher?

Secure Information

Please supply the following information: Social Security Number/Humboldt ID and Date of Birth
This information is submitted via SECURE SERVER, and is requested pursuant to Section 41201, Title 5, Calif. Code of Regulation and Section 6109 of the Internal Revenue Code.

Social Security Number or Humboldt ID (000-00-0000):required

Your date of birth is required so that Cal Poly Humboldt may identify records that are unique to you.

required

Race/Ethnicity Information

Your voluntary response is requested to comply with Federal and State legislation. If the California State University system is asked to report only ONE summary race/ethnicity description for you, choose the ONE category below that you want us to report:

 
Course Registration

Enter the course information and indicate the term and year each course was completed.

Course 1
$
Course 2
$
Course 3
$

$

$

Payment of Fees

If you owe a fee, please select how your fees will be paid. If you do not wish to make an online payment upon submitting this form, please select one of the other payment options.

NOTE: All Cal Poly Humboldt students will be charged a 2.65% card processing fee when making a credit or debit card payment, whether it's in person, by phone, or through this registration/payment form.

To avoid the card processing fee, you can choose to pay via electronic check in the online payment portal, or pay with a paper check/money order in person or by mail.

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