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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): ___________________________________________________________