Registration Form 5 convenient ways to register: Mail print out and complete this form. Fax 785/864-5074. Phone 785/864-4790, 8:00 a.m. to 5:00 p.m. (CST) Monday through Friday .
	E-mail bproctor@ukans.edu. Web site: Complete and submit this form. Please provide all information requested on the registration form. If you register electronically, we will contact you for payment information. We will send a confirmation immediately upon receiving your registration. If you do not receive a confirmation call, or letter within 14 days, please call 785/864-4790. Thank you.
*Denotes required fields. Title (Mr.,Ms.,Dr.) *Name Social Security Number Affiliation/Department/Institution Street Address or PO Box City State ZIP/Postal Code Country *Telehone Fax *E-mail Address Fees Conference registration (includes two continental breakfasts, two lunches, breaks, and all conference materials) $275 Wednesday dinner at the KU Natural History Museum $35 Total $ Payment Options Check enclosed (Payable in U.S. dollars to "The University of Kansas")* *For use only with printed forms submitted by regular mail. Note: This is not a secure transaction. Credit card information is optional. You will be contacted by a continuing education representative to confirm registration and make billing arrangements. VISA MasterCard Card Number Expiration Date Cardholder's Name Special Accommodations If you will need special accommodation, please check the space below and you will be contacted personally by a member of the Continuing Education staff. How did you first hear about our short courses? Referral KU brochure Magazine ad WWW page KU postcard Article or listing Have you attended a KU course or seminar in the past? Yes No We will confirm your information and discuss your payment arrangements upon receipt of your online registration. Main Page | Featured Courses | Conference Program | General Information | Registration Form APP Home CE Home | KU Home | Edwards Campus Home | KU Medical Center Home Site Search | Staff Directory | About KU Continuing Education | Program Calendar This page maintained by cewebster. The University of Kansas Division of Continuing Education 1515 St. Andrews Drive Lawrence, KS 66047-1625, USA URL: http://www.kumc.edu/kuce/app/online/regform.html Page last modified Friday, March 12, 1999.