REGISTRATION FORM

L.E.A.D. Lifelong Education And Development

Simply fill out the the information below ONLINE: Go to troy.edu/ce and follow instructions under Registration and send it in. Feel free to copy this form for BY PHONE: (334) 983-0005 additional registrations and if you have any BY FAX: (334) 983-0009 questions, give us a call! BY MAIL: Continuing Education and Outreach, P.O. Box 8368, Dothan, AL 36304 IN PERSON: Come to Malone Hall, Room 304

______First Person (PLEASE PRINT CLEARLY) Second Person (PLEASE PRINT CLEARLY)

______Address Address

______City State Zip City State Zip

______Home Phone Work Phone Email Home Phone Work Phone Email

______First Course ID/Title First Course ID/Title

______Date Time Cost Date Time Cost

______Additional Course ID/Title Additional Course ID/Title

______Date Time Cost Date Time Cost

Birthdate ______/ ______/ ______(for official use only)

Continuing Education and Outreach HOW DID YOU FIND OUT ABOUT US? administrative offices are located at: 501 University Drive q Direct Mail q Email q Newspaper/MagazIne Malone Hall, Room 304 q Referral q Website q Facebook Dothan, AL 36303 METHOD OF PAYMENT Operating Hours: q MasterCard q Visa q American Express q Discover Monday - Thursday, 7:45 am - 5:30 pm q Cash (in person only) q Personal Check (payable to Troy University) Friday, 8:00 am - 12 noon q Company Check (payable to Troy University) q ______For more Purchase Order Number information: T: 334.983.0005 ______Credit Card Number Expiration Date E: [email protected] ______Pre-registration is required for all courses. Name on Credit Card CSC/CVV (3-Digit Code)

Payment MUST be made at time of registration. ______Signature (if paying by credit card)

T: 334.983.0005 | F: 334.983.0009 | troy.edu/c