E-Mail Registration Form

Name (Required)

Date of Birth: (Required)

/mm/dd/yyyy:

Male/Female

Male
Female

Address: (Required)

City/State/Zip: (Required)

Day Phone: (Required)

Evening Phone: (Required)

Fax Number:

Your E-Mail Address (Required)

Ethnic Origin:

Please check categories that apply. Response is voluntary and information will be kept confidential. Refusal to provide this information will not be subject to any adverse treatment:

American Indian/Alaskan Native
Black/Non Hispanic
Hispanic
White/Non Hispanic
Haitian
Asian or Pacific Islander
Other

Other:

Ethnic Origin: Other

Have you ever been convicted of a felony? (Required)

Yes
No

Have you ever been dismissed from college for disciplinary reasons? (Required)

Yes
No

Felony/Disciplinary: A felony in New York State law is defined as a crime for which more than one year in prison may be imposed. The felony question applies if you have been convicted as an adult. I hereby certify that the above statements are true and correct to the best of my knowledge.

If you answer yes to either question you will receive a letter requesting further information. Answering yes to either question does not automatically bar an applicant from admission. A campus committee will then review information provided. You must answer this question. Failure to do so will suspend the processing of your application.

Course Number -1 (Required)

Course Title/Date - 1 (Required)

Fee - 1 (Required)

Do not enter $ sign or decimals

Course Number - 2

Course Title/Date - 2

Fee - 2

Do not enter $ sign or decimals

Course Number - 3

Course Title/Date - 3

Fee - 3

Do not enter $ sign or decimals

Total Fees:

Do not enter $ sign or decimals

Please charge my (Required)

VISA Card
MasterCard
Discover Card

Account No. (Required)

Expiration Date: (Required)

Card Holder Name:

(If different than above)


	E-mail: conted@sunyrockland.edu

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