Emerson Theological Institute - Application for Student Enrollment

Emerson Theological Institute PO Box 2127 Oakhurst, CA 93644 Distant Learning Application Class Registration for Distant Learning Classes Please print, complete and mail this form
Date:
Your Name:
Mailing Address:
City, State, Zip Code/Postal:
Country:
Social Security Number:
Day Phone:
Evening Phone:
Email Address:

Class Title:
Units:
Semester Unit Cost:	$75/unit X ________ units = $ _________
Books:	$______________
Materials:	$______________
Total:	$______________
Payment Method:	___ Cash/Check enclosed for $________ (check made payable to Emerson Institute) ___ Credit card payment of $__________ _____Visa _____ MasterCard _____American Express Card Number: _____________________ Expiration Date: _____________ *Name on Card:(please print)* _____________________________________ Enrollee's Signature: __________________________________________ Date: __________________________**