Ways to Enroll in an ACT Course

Until we are able to set up a secure server, we need to ask you to subit your enrollment "the old fashioned way." Thanks!

CALL US, OR FAX ENROLLMENT Call 1-800-916-2818 to enroll over the phone, or print out and fax the form below to (714) 751-9065 to enroll immediately with your MasterCard, VISA, or Discover Card,

OR

PRINT AND MAIL this form along with your check (payable to CSUMB) or your credit card information to: CSUMB ACT Program, 3151 Airway Ave,
#B-2, Costa Mesa, CA 92626 • (Purchase Orders Accepted.)

Today's Date: __________________

Please enroll me in the following course(s): (please print or write CLEARLY. Titles can be brief. Thanks!)

Course No.: ___________ Course Name: ___________________________________________

Course No.: ___________ Course Name: ___________________________________________

Course No.: ___________ Course Name: ___________________________________________

Course No.: ___________ Course Name: ___________________________________________

Course No.: ___________ Course Name: ___________________________________________
WHEN ENROLLING IN AN INTERNET COURSE, please specify all materials (all) or worksheets only (w/o) and whether or not you want your assignments delivered in hard copies (hc) or via the Internet (I)

Enclosed is my check in the amount of $___________, OR

please charge my (underline one) MasterCard • VISA • Discover

#____________ ____________ _____________ ____________ Exp. Date: ________________

3-Digit Code on back _______ Signature: ____________________________________________

Name as it appears on the Credit Card: ______________________________________________

Name (as you would like it on the University Records):

__________________________________________________________Male____Female____

Street Address: _______________________________________________________________

City: __________________________________________ State: _____ Zip: _______________

Date of Birth: _______________ SSN: _______________________________________

Phone Number: (_____) __________________________

School District: _______________________________________________________________

email Address: _______________________________________________________________