Student-Faculty Spouse Online Registration Form

An asterisk (*) indicates a required field.

Name (First, Initial, Last):*
Spouse Name (First, Initial, Last):*
Local Street Address:*
City:*
State:*
Zip Code:*
Home/Cell Phone:*
Work Telephone:
Extension (if applicable):
Permanent Street Address:
City:
State:
Zip Code:
Email Address:*
Patron Type: Regent/CBN Student Spouse
Regent/CBN Faculty Spouse