Office of Educational Outreach

For Enrollment Instructions click here

Term_____________________Year_____________________Today's Date__________________

Course Location_________________________________________________________________

Last Term Attended at SIUE (on or off-campus)_________________________________________

Name_________________________________________________________________________
                            Last                                                                          First

University ID Number_________________________Daytime Phone_______________________

Address_____________________________________Email______________________________

City________________________________________State____________Zip________________

List Courses you are taking this term, both on and off campus

1. _____________________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

5. _____________________________________________________________

Payment Type (Circle one) :

_____Check ( Payable to SIUE )                                    Bill to Company/Agency_____

_____MasterCard                                                           Cooperating Teacher (Attach form)_____

_____VISA                                                                     Illinois Veteran Grant_____

_____Discover

Amount of Payment________   Received By_______   Payment Type_______  Date________