CSU Pueblo Siedow Registration

Please fill in a valid value for all required fields

Please ensure all values are in a proper format.

Are you sure you want to leave this form and resume later?

Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.

You must upload one of the following file types for the selected field:

There was an error displaying the form. Please copy and paste the embed code again.

There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.

CSU Pueblo Siedow Registration

* Indicates required field

Registration with Siedow is required prior to filling out this registration form.

Term:*

Course Loading Status

Advisor

Program

Courses:*

Select Up to 6 Courses

Course Label List

Full Legal Name:*

First Name*

Middle Name (optional)

Last Name*

CSU Pueblo NetID:

Enter NetID if known

Date of Birth:*

https://csupueblo-extendedstudies.formstack.com/forms/images/2/calendar.png

Month

Day

Year

Example: mm/dd/yyyy

Re-Enter Date of Birth:*

https://csupueblo-extendedstudies.formstack.com/forms/images/2/calendar.png

Month

Day

Year

Example: mm/dd/yyyy

Error: Date of Birth fields must match.

Social Security Number:

9 Numbers, no spaces

Address Type

Domestic International

Mailing Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Country

International Mailing Address:*

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

Phone Type

Domestic International

Home Phone:

Cell Phone:*

International Home Phone:

International Cell Phone:*

Email:*

Confirm Email *

Gender:*

Male Female Not Available

Primary Citizenship:*

U.S. Citizen Non U.S. Citizen on Permanent Status Non U.S. Citizen on Temporary Status

Country of Permanent Residence:

Disclosure of ethnicity and race information is voluntary and responses will not be used in a discriminatory manner.

Ethnicity (Select One):*

Hispanic/Latino (includes Chicano, Cuban, Puerto Rican, Mexican American) Not Hispanic/Latino

Race:

American Indian or Alaska Native (Original Peoples) Asian, Japanese, Chinese, Vietnamese, Korean, Filipino (including Indian subcontinent) Black, African American (including Africa and Caribbean) Native Hawaiian or Other Pacific Islander (Original Peoples) White, Anglo, Caucasian (including Middle East, Persia)

Do you have a master's Degree?*

YES NO

Are you interested in learning more about CSU Pueblo's Online Master of Education Degree Program?*

YES NO

CLICK HERE for more information

Are you interested in learning more about CSU Pueblo's Online Doctorate of Education Degree Program?*

YES NO

CLICK HERE for more information

Have you previously taken a course through CSU Pueblo?

Yes No

Please indicate if any of the following apply:

Are there any pending criminal charges against you?*

Yes No

Do you have any prior convictions OR prior disciplinary history at another academic institution (including pending disciplinary proceedings) for stalking, sexual assault and/or domestic violence?**

Yes No

Have you had any convictions within the past five years before submitting this application for assault, kidnapping, voluntary manslaughter or murder?*

Yes No

*A conviction by a jury verdict or by entry of a verdict or acceptance of a guilty plea or a plea of nolo contendere by a court. Conviction

Please provide an explanation to help us review your application. You are not required to disclose any information contained in sealed records and you have the right to appeal any decision based on prior conduct or convictions.

I understand and agree that if at any time after submitting this application, I am arrested and charged with any crime, OR if I am convicted* of stalking, sexual assault, domestic violence, assault, kidnapping, voluntary manslaughter or murder, OR I am found responsible for stalking, sexual assault, or domestic violence (or disciplinary proceedings are initiated for stalking, sexual assault, or domestic violence) by any school or educational institution of any type, whether public or private, then I am required to disclose any and all such information in writing to the Director of Admission at the Colorado State University Pueblo or, once I have enrolled at CSU Pueblo, to the Director of Student Conduct. I also understand and agree that such information may result in the delay, rejection or revocation of admission to, or loss of credit or dismissal from CSU Pueblo.

The University can only inquire about specific criminal history during the admission process. However, certain programs may have criteria that may preclude you from completing coursework and/or obtaining licensure in your field based on criminal history not inquired about on this application. For example, the University cannot inquire about drug convictions on your application; however, a drug conviction may prevent you from obtaining licensure in some fields. Please contact the academic department and/or the state licensing board to determine if your criminal history may prevent you from completing coursework or obtaining licensure.

I understand and agree with the statements above.

Signature*

[clear]

Use your mouse or finger to draw your signature above