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For a printable (.pdf) copy of the registration form visit the download forms page. Or you may print the form below by simply clicking print from your browser menu bar. After you fill out the Registration Form, you may register by fax, phone or mail as described in the instructions on the enrollment page.

Name: (first) ________________________ (m.i.) ______ (last) ____________________________

Social Security Number: (domestic students only) ______________________________________

Mailing Address:

Street: ___________________________________________________________

City: _______________________ State: _______ Zip Code: _______ Country: __________

Home Phone: ______________ Business Phone: ___________ E-mail: __________________

Please select from the following category:

__ I am enrolled in the MS Degree Program

If so, please indicate your area of concentration:

__ Computer and Information Sciences (CIS) [no area of concentration]
__ Information Security (IS)
__ Bioinformatics (BI)
__ Knowledge Management (KM)
__ Software Engineerings (SE)
__ Computer Networks (CN)
__ Management Information Systems (MIS)
__ Digital Art (DA)
__ Computer-based Education (CBE)

__ I am enrolled in a certification program

If so, please indicate the program:

__ SAS Certification Program
__ Bioinformatics Certification Program
__ Oracle DBA Certification Program
__ IT Certification Program
__ Network+ Certification Program
__ Information Security Certification Program
__ Sun Java 2 Certification Program
__ Digital Art Certification Program

Please list course(s) (see the online catalog for course listings):

Course	Course number (i.e., CIS310)	Amount enclosed ($1,265.00* per course for domestic students, $1,487.00** per course for foreign students)
1.________________	________________________________________	_________________
2.________________	________________________________________	_________________
3.________________	________________________________________	_________________
4.________________	________________________________________	_________________
5.________________	________________________________________	_________________
	Add 3% of total if payment by credit card -->	_________________
	Total amount enclosed or to be charged -->
		===============

* This includes $1110.00 tuition, $5.00 material fee and $150.00 distance learning lab fee.
** This includes $1,332.00 tuition, $5.00 material fee and $150.00 distance learning lab fee.

Payment Method

__ by check (please enclose check or money order payable to Knowledge Systems Institute)

__ by Visa or __ Mastercard (please fill out the following)

Name as it appears on credit card: ________________________________________________
Credit card number: ___________________________________ Expiration Date:___________

Your Signature: _____________________________________

How did you hear about the DL Program? (please check one)

__ Internet search engine
__ Chicago Tribune
__ Other printed ad
__ Printed listing
__ Internet listing
__ Friend or Alumni
__ Other _______________