Information For

Healthcare Information Technology Certificate Program Application

If there are changes to any of the information contained on this application after submission, it is your responsibility to notify Extended Learning at el@csusm.edu.

DO NOT SUBMIT UNTIL YOU COMPLETE THE APPLICATION

*
*
*

*
*
*
*
*
*

*
*
*
Yes
No

*
*
*
College/University graduated from or are currently attending. Official transcripts required for each institution listed. Applications are not complete until transcripts are received.

*



*
*
*

If yes, please list your Visa status

If yes, please list dates of service
*
*
Bachelor's degree
Completion of college algebra or equivalent

*
*
*
*
Full Name and Date
Loading reCAPTCHA...
Submit