College of Extended Education and Global Engagement

In partnership with the

TEACHER INDUCTION PROGRAM
MENTOR
ACADEMIC CREDIT REGISTRATION FORM

If you would like to pay with a credit card (VISA, MC or Discover) or by electronic check,
please use this form to register for Teacher Induction classes.
Upon your submission of this form, you will be directed to the CASHNet online payment system,
where you will enter your credit card or electronic check information.

DO NOT USE THIS FORM FOR RETROACTIVE CREDIT

To request retroactive credit (for terms up to one year prior to the current term),
please begin the process by contacting the NCTIP office at (707) 524-2818,
during business hours. Allow up to four weeks for your request to be processed.

Student Information

= Required field

First Name

MI

Last Name

E-mail Address

Mailing Address

Mailing Address Line 2

City

State/Province/Region

Country

ZIP/Postal Code

Daytime Telephone (include area code)

Mobile Telephone (include area code)

Select your gender:

Male

Female

Decline to state

Have you ever been enrolled at Cal Poly Humboldt?

YES

NO

List all previous names you have used. (Examples: Birth Name, Maiden, Previous Marriage, Legal Name Change)

Have you completed a Bachelor's Degree or higher?

YES

NO

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):
- -

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

Month:
Day:

Year (4 DIGIT):

Course Credit

Mentor Fall Year 1, 2 units (44158): $100 $

Mentor Fall Year 2, 2 units (44159): $100 $

TOTAL TO BE CHARGED:
You will enter your credit card or electronic check information after submitting this form. $

Submit the form

Please check the box to confirm you are a human before you submit this form.
You may also be required to verify one or more Recaptcha images. Thank you for helping us prevent spam.
Please review the above information for accuracy before submitting this registration form.

Once you submit the form successfully, you will be directed to the payment system.

Mentor Fall Year 1, 2 units (44158): $100	$
Mentor Fall Year 2, 2 units (44159): $100	$
TOTAL TO BE CHARGED: You will enter your credit card or electronic check information after submitting this form.	$

TEACHER INDUCTION PROGRAM MENTOR ACADEMIC CREDIT REGISTRATION FORM

Secure Information

TEACHER INDUCTION PROGRAM
MENTOR
ACADEMIC CREDIT REGISTRATION FORM