UW - Milwaukee, School of Continuing Education Registration Form
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To complete your registration, fill out the form below and Mail to:   School of Continuing Education University of Wisconsin-Milwaukee Drawer No. 491 Milwaukee, WI 53293-0491   Or Fax to:   1-800-399-4896 or (local) 414-227-3146
PERSONAL INFORMATION: Full Name: ______________________________ Business Title: ______________________________ Organization Name: ______________________________ Your confirmation and any correspondence will be sent to the address below. Street Address: ______________________________ City: ______________________________ State or Province: ______________________________ Zip or Postal Code: ______________________________ Country: ______________________________ Daytime Phone: ______________________________ Evening Phone: ______________________________ Fax: ______________________________ E-mail Address: ______________________________ If you need special accommodations, please describe. Request will be kept confidential. ________________________________________________ Comments: ________________________________________________ Yes! I would like to receive program information by e-mail. No. Please do not send program information by e-mail.	BILLING INFORMATION: Credit Card Payment Credit Card Type: AMERICAN EXPRESS MASTER CARD VISA Card Number: ______________________________ Expiration Date: ______________________________ Cardholder's Name: ______________________________ Billing Address: ______________________________ Billing Zip Code: ______________________________ Bill My Organization Purchase Order #: ______________________________ Attention: ______________________________ Phone: ______________________________ Address: ______________________________ City: ______________________________ State or Province: ______________________________ Zip or Postal Code: ______________________________ Country: ______________________________ Check Enclosed Mail to: School of Continuing Education University of Wisconsin-Milwaukee Drawer No. 491 Milwaukee, WI 53293-0491
If you found out about this course through a catalog, brochure, or email, please enter the codes located to the left of the name on the mailing label, or the codes referenced in the email.
Keycode: ______________________________     Message Code: ______________________________