Distance Learning > Supplementary Registration Form

Supplementary Registration Form

Complete this form if you are enrolling in any distance learning courses. Please print this page, complete the following information and send it in with your registration form.

Course title and number:

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Instructor:

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Your name:

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Address where you will be taking this course:

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Phone number where you will be taking this course:

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Home phone number:

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Email address where you will be taking this course:

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Mail or fax to:

School of Continuing Education and Summer Sessions
B20 Day Hall
Ithaca, NY 14853-2801
Phone: 607.255.4987
Fax: 607.255.9697
Email: cusce@cornell.edu