Sam Houston State University A Member of The Texas State University System Correspondence Course Division P.O. Box 2536 Huntsville, Texas 77341-2536 (409)294-1003 (409) 294-1005 (409) 294-3824

Please be sure to fill out both pages and sign this two page application.

You may pay by check (include Social Security Number and Driver's License Number on check) or by VISA/MasterCard.

Card Number _________________________________________ Expiration Date ________________

Signature __________________________________________________________________________

Date of Birth	_____________	| ____________	| ______________
	Month	Day	Year

Social Security Number _______ | ______ | _________ Driver's License Number _________________

Home Phone (______) ________________ Work Phone (______) ________________

Name ___________________________________	_____________________________	_______________________
Last	First	Middle or Maiden

SHSU students, please note: The address listed as your Permanent Address at SHSU is utilized by the Correspondence Course Division.

Mailing Address	__________________________________	_______________________	______	_____________
	Street, P.O. Box, Route. Apt. No.	City	State	Zip Code

Course prefix and number for each course applied for, and please circle its type:

(1)____________________ (On-line / Regular) (2)____________________ (On-line / Regular)

Have you previously taken these courses in the classroom? Yes ____ No ____ If yes, grades received _____________

Anticipated date of graduation from SHSU or receiving teacher’s certification: _____________________________

Are you presently enrolled in any college or university? Yes ____ No ____ SHSU? Yes ____ No ____

Are you exempt from taking the TASP Test? Yes ____ No ____

For students who have not earned nor attempted any college course work, please complete the following.

High School Graduate Yes ___ No ___ Date: _________

GED? Yes ___ No ___ GED Scores ___________________________

You must attach an official high school transcript and/or GED test scores in order for this application to receive consideration.

If I am subject to the provisions of TASP, I authorize Sam Houston State University (SHSU) to obtain my TASP scores from the Texas Higher Education Coordinating Board (THECB). I hereby, knowingly, freely, and voluntarily waive any right or cause of action arising as a result of the transmission of my TASP test scores from which any liability may or could accrue to SHSU/TSUS/THECB and/ or the State of Texas. I certify that the information contained in this application is true and correct. I understand that the written answers to all lessons, tests or examinations submitted by me for grading and/or credit in this correspondence course must be my own work. I agree that I will comply with all rules and regulations as set forth in the current SHSU Correspondence Bulletin. I understand that my failure to submit original work and/or to follow the aforementioned rules and regulations may result in my being disenrolled from this course without credit. I further understand that the use of abusive, indecent, profane or vulgar language, which by its very nature is offensive to others, will not be tolerated in any correspondence course work submitted by me. Any such occurrence may be grounds for disenrollment from a correspondence course without credit. _______________________ _________________________________ Date Signature