If there are changes in any of this information after submission,
it is your responsibility to notify Extended Learning
at vmartine@csusm.edu

DO NOT PRESS THE "ENTER" BUTTON UNTIL YOU COMPLETE THE APPLICATION

Last name:     First Name:     MI:

OTHER NAMES THAT MAY APPEAR ON YOUR ACADEMIC RECORDS
Last name:     First Name:     MI:

ADDRESS:
Street      City       State  
Zip Code   
 
PERMANENT ADDRESS (if different):
Street       City       State 
Zip Code   

PHONE NUMBERS (example format:  760-456-7890):
               Home:                          Cell phone:  

Email address (Required)      
If you do not currently have an email account, please set up a free account at: www.hotmail.com so that we may contact you by email, if needed. (Using this link will open another window where you can obtain an e-mail account. When you are done, close that window and return to the form.)

I am presently enrolled at Cal State San Marcos?     Yes      No

CSUSM Student ID number: 


COLLEGES AND UNIVERSITIES ATTENDED OR ATTENDING

FOUNDATIONAL SCIENCE CLASSES

In the table below include all successfully completed courses to be used for meeting the Foundational Science Classes requirement, with grades of C or better.  If the course is in progress, list the term the course is being taken (e.g. - Fall 2008) and type "IP" in the grade column. 

U.S. Veteran:  Yes   No

Dates of Military Service:

Ethnicity or Race: 

Baccalaureate degree or higher degree?  Yes   No

Discipline:

Degree Received:

If employed, name of employer:

Position:

Does your employer offer tuition assistance?  Yes   No

RESIDENCY

State of Residence:

I certify that all information provided in connection with this application is true, correct and complete.  Providing false information or omitting required information is fraud and grounds for denial of enrollment or immediate expulsion from the Master of Biotechnology (MBT) program.

Type Name:         Date:

If you have any questions or comments, please contact us by email at:
vmartine@csusm.edu

Be sure to include your full name in any email communications.