POC Name: 
Affiliate Account Request
Last Name:First Name:
*  * 
Date of Birth:Last four digit of SSN:
*   *   
Email address: Department assigned:
*   * 
Job Title and/or Role:UCSD Sponsor Name:
*  * 
Name of UCSD-sponsored Program Sponsor's Email address
*  *  
Which courses would you like to enroll in?