Post on 14-Aug-2020
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Version 11.18.15
Corporate Travel Agent Certificate Application Form
ABSOLUTELY NO CASH OR CHECKS WILL BE ACCEPTED – VISA or MASTERCARD ONLY!You can register by FAX: 408-924-2609 or mail to the above address ATTN: CEU Programs
Please call if you have additional questions regarding this registration form: 408-924-2685
• A request form must be submitted for each course.• The following personal information will be kept confidential.• A $25.00 fee will be incurred if credit card payment fails to clear.• There is a “No Refund Policy” for this course if your application is approved and you are selected.
Personal Information (Please print or type)
Have you attended SJSU before? Yes No
First Name: __________________ M.I.: _____ Last Name: _________________
Other Last Name used at SJSU: ___________________ Date of Birth: _____________ Male Female
SJSU Student ID (if any): _________________________ Education Level: ____________________________
Current Mailing Address: _____________________________________________________ Apt #: ___________
City, State, Zip Code, Country: _____________________________ E-Mail Address: ______________________
Phone Number: _________________________ Cell Phone Number: __________________________________
COURSE FOR WHICH YOU ARE REGISTERING:
Year: Course Title:
Term:
Dates:
CEUs:
Course Number: Course Fee: Total CEUs = Total Amount =
VISA MASTERCARD __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date __ __ - __ __
Total Amount Charged = Cardholder’s Name: _______________ Signature __________________
TRANSCRIPT REQUEST (no fees for first 1-5 copies)
Quantity: Official _____ Unofficial ______ Signature:
Mailing Address (if different than above): ___________________________________________________________