Printable Mail/Fax Registration Form

Payment required with registration

 

Please:	Use a separate form for each person or program. Print this page and fill it out completely.
Fax:	715-836-5263   |   Toll-free: 1-800-835-3755 MasterCard, Visa or purchase order only.
Mail:	Complete and mail registration form to: UW-Eau Claire Continuing Education P.O. Box 4004   |   Eau Claire, WI  54702-4004 Include check, money order, purchase order, MasterCard or Visa.

 

Name of Program :__________________________________________________

Date of Program: __________________________________________________

Place of Program: __________________________________________________

Fee of Program: ___________________________________________________

Name of Registrant: ________________________________________________

Home Address: ____________________________________________________

Home City: ________________________________________________________

Home State: ______________Home Zip Code: ___________________________

Home Phone Number: _______________________________________________

E-mail: ___________________________________________________________

Secondary e-mail: _________________________________________________

Employing Company: ________________________________________________

Company Address: _________________________________________________

Company City: _____________________________________________________

Company State: _______________Company Zip:_________________________

Position: _________________________________________________________

PO Number: ______________________________________________________

METHOD OF PAYMENT

______ Check enclosed: Ck# ______________________ Amount: $_________

______ Credit Card (circle one): Mastercard or Visa

Card Number: _______ - _______ - ________ - _________

expiration date: _________

Card holders name (print): __________________________________________

Card holders signature:___________________________________________________

I would like to be included on your mailing list for future programs: (please circle) Yes or No

I would like to be included on your e-mail mailing list for future programs: (please circle) Yes or No

It is our policy not to share, sell or distribute the contents of our mailing lists or e-mail lists to organizations outside of the University of Wisconsin-Eau Claire.

Questions? Call (715) 836-3636