WHO MAY APPLY

• UCI and UCIMC Faculty and Staff

HOW TO APPLY

• Complete both sides of this form
• Present form to the UCI Extension Registration Office or return by intercampus mail to:
  UNEX Registration - Zot Code 5700
• Fee must be paid at the time of registration

ENROLLMENT POLICY

Enrollment for students applying for a 50% reduction in course fees will be processed, space permitting, just prior to the start date of the class. Full paying students are always given priority in the enrollment process. The student or department may choose to pay the full fee to guarantee a space in the class, with the option of requesting a 50% refund of fees if the class does not reach is enrollment capacity. The request for a 50% refund must be initiated by the student within one week of the start date of the class.

University Extension reserves the right to exclude from this arrangement certain programs such as ACCESS UCI/CONCURRENT COURSES, SUMMER SESSION COURSES and COMPUTER LAB COURSES.

Please choose one of the following enrollment options:
   1. Enroll at the full fee to secure a space in the class
          If the class does not fill, the employee is eligible for a 50% refund of course fees. The employee must contact the
          Registration Office one week after the class start date to initiate the refund process. No refunds will be processed
          after this time.

For questions, call UNEX at (949) 824-5414

OFFICE USE ONLY: QTR          F   W   SP   SU         DATE                                       CHARGED FEE                        ACCOUNT                                RECEIPT

REDUCED FEE APPLICATION

TO BE COMPLETED BY APPLICANT (please print or type):

INDICATE EMPLOYMENT STATUS:

Faculty

Staff -

____Career

____Casual

NAME: FIRST		MI				LAST
CAMPUS DEPARTMENT/LOCATION
JOB TITLE			UCI EMPLOYEE ID#
HOME ADDRESS
CITY				STATE				ZIP
DAY PHONE			NIGHT PHONE
E-MAIL ADDRESS
SOCIAL SECURITY NUMBER			DATE OF BIRTH
REG #	DEPT/COURSE#				UNITS		START DATE
HOW DID YOU OBTAIN COURSE INFORMATION?   CATALOG    BROCHURE     OTHER

PAYMENT SECTION:

FEE RECHARGED TO DEPARTMENT: AMOUNT TO BE RECHARGED:  50% $____________ OR  100% $____________ I certify that the applicant is a UCI Employee. ACCOUNT NAME:____________________________________________________ACCOUNT & FUND___________________________________ DEPT HEAD NAME (PRINT OR TYPE) __________________________DEPT HEAD SIGNATURE___________________________DATE__________

FEE PAID BY STUDENT: AMOUNT TO BE PAID:   50% $_________ or   100% $_________ PAYMENT OPTION:   Cash                       Check ~ MAKE CHECKS PAYABLE TO:  "UC REGENTS"   Mastercard             Visa                      American Express Credit Card #_______________________________________________________________ Exp (month/year)_____________________ Signature_______________________________________________________________________________________________________

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Rev: 5/05