<p> Process Engineering R&D Center Short Course Registration Fax to 979.845.2744 Attn: Short Course Coordinator</p><p>Please Type Your Information</p><p>Name of Course: </p><p>Dates of Course: </p><p>Full Name: (Full name as it will appear on your diploma)</p><p>Job Title: </p><p>Company: </p><p>Mailing Address: </p><p>City: State: </p><p>Zip Code: Country: </p><p>Business Phone: </p><p>Fax: </p><p>E-mail: </p><p>Name for Nametag: (Name you would like to be called)</p><p>Contact in case of emergency: </p><p>List any special diet requirements: </p><p>Method of Payment: (mark one)</p><p>Check Payable to TEES</p><p>If paying with credit card, please include type of card: (circle one)</p><p>American Express Visa Master Card</p><p>Credit Card Number: </p><p>Expiration Date: </p><p>Name on Credit Card: </p><p>Verification Code on back of Credit Card: Billing Address</p><p> of Credit Card:</p><p>Total Amount: </p><p>Signature: </p>