This form must be completed in order to be registered for an online course. If you are planning on taking an online course and have not completed this form in the registrar's office - you must complete this form and return it to KAB 221.

Please note: this form must be completed and submitted with your Pink Registration Form - EVERY SEMESTER. Also, completing this form DOES NOT REGISTER YOU FOR YOUR ONLINE COURSE. The information on this form is used to create and account so you can access the online course material and provide a way (via e-mail) for your course instructor to contact you regarding course assignments, chat sessions, etc.

Distance Education Student Information Form Semester: ____________

Have you have taken an INT course in the past? YES NO

Is E-mail address the same? YES NO

Student Name:

(LAST name) _____________________________________________________

 
(FIRST name) _____________________________________________________

 
Student Social Sec. #: ___________________________________________________________

 
Phone #'s: Home: ____________________________ Other: ____________________________

 
E-mail address (REQUIRED) _____________________________________________________

IF YOU DO NOT HAVE E-MAIL, PICK UP YOUR PERSONAL DYC E-MAIL ADDRESS IN AC-8.

THEN NOTIFY TOM MILANO (RM. AC-4, (716) 829-8133) REGARDING THAT E-MAIL ADDRESS.

List Internet Courses Registered for:

 Course ID#1:_________ Course Name:___________________ Instructor:__________________

 
Course ID#2:_________ Course Name:___________________ Instructor:__________________

 
Course ID#3:_________ Course Name:___________________ Instructor:__________________

 
Course ID#4:_________ Course Name:___________________ Instructor:__________________