Last Name: ___________________________________________________________________________________

First Name: ________________________________________________ Middle Name: ______________________

Address: ______________________________________________________________________________________

City: __________________________________________State: __________________ ZIP: __________________

Employer: _____________________________________________________________________________________

Title: _________________________________________________________________________________________

Social Security Number: _________________________________________________________________________
A Social Security number is required to process a refund.

Phone: Day (______) _____________________________ Evening (______) _____________________________

Fax: (______) _____________________________ E-mail: ____________________________________________

Billing Address (if different than above):

Address: ______________________________________________________________________________________

City: __________________________________________State: __________________ ZIP: __________________

COURSE(S):

Course Title: __________________________________________________________________________________

Course #: ________________ Reference # : ________________ Location: ______________________________

Course Title: __________________________________________________________________________________

Course #: ________________ Reference # : ________________ Location: ______________________________

Course Title: __________________________________________________________________________________

Course #: ________________ Reference # : ________________ Location: ______________________________

I wish to receive: _____Undergraduate Credit _____Graduate Credit _____Audit*
*Auditors are charged full fees and receive no academic credit.

If you have taken credit courses before at UM–St. Louis, indicate if they were offered:

_____On Campus _____Through Continuing Education

Last year enrolled at UMSL:______ Hours completed: ______ Student ID# (if known)____________________

Are you now under suspension or dismissal by any college or university? _____Yes _____ No

Signature: ___________________________________________________________________________________
Note: A more detailed application may be sent to you to ensure your enrollment.

Payment

___ Check enclosed. [Make check payable to the University of Missouri-St. Louis.]

___ Bill me. [If you choose this option, you will receive a bill from the Cashier’s Office. You will be able to pay your fees by check, e-check, cash, PIN-based debit card, MasterCard, or Discover. Credit card payments will be assessed a 2.75% (subject to change) service charge by the company processing the transaction.]

NOTE: For security reasons, do not e-mail this form.