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: ______________________________