Last Name: ___________________________________________________________________________________
First Name: ________________________________________________ Middle Name: ______________________
Address: ______________________________________________________________________________________
City: __________________________________________State: __________________ ZIP: __________________
Employer: _____________________________________________________________________________________
Title: _________________________________________________________________________________________
Phone: Day (______) _____________________________ Evening (______) _____________________________
Fax: (______) _____________________________ E-mail: ____________________________________________
Billing Address (if different than above):
Address: ______________________________________________________________________________________
City: __________________________________________State: __________________ ZIP: __________________
Please register me in the following Continuing Education noncredit course(s) or program(s):
Title: __________________________________________________________________________________
Section: ________________ Fee: ________________
Title: __________________________________________________________________________________
Section: ________________ Fee: ________________
Title: __________________________________________________________________________________
Section: ________________ Fee: ________________
Payment Information
Payment will be made by:
_____Check (Make check payable to the University of Missouri-St. Louis.)
_____MasterCard _____Visa _____Discover (You must include card number, expiration date, and amount below.)
Card #: ___________________________________ Expiration Date: _______________ Amount: ______________
Signature: ______________________________________________________________________________________
By mail or fax:
Mail or fax completed form with payment to:
University of Missouri-St. Louis
Continuing Education
201 J.C. Penney Conference Center
One University Blvd.
St. Louis, MO 63121-4400
Fax: (314) 516-6414
|
By phone or TDD:
Call (314) 516-5961.
Charge card number or other payment
information must be included.
|
NOTE: For security reasons, do not e-mail this form. |
