(Printable form- Use your browser’s Print icon to print)

Mail To:                                                                                                                   Email to:
Registration Services                                                                                          registration_services@ua.edu

The University of Alabama
Box 870398
Tuscaloosa, AL 35487

 

Please submit this entire page for your registration. For multiple registrations, please duplicate this form.

[ ]Mr. [ ]Ms. [ ]Dr. First:____________________________Middle Initial:________Last:____________________________

Preferred Name/Nickname:____________________________

Company/Organization Name:____________________________

Mailing Address:____________________________City:____________________________State:________Zip:______________

Email Address:____________________________Phone:____________________________

Job Title:____________________________

[ ] Enclosed is a check for $____________________________ made payable to THE UNIVERSITY OF ALABAMA

[ ] Purchase order is attached.

[ ] Charge $____________________________to credit card: [ ] MasterCard [ ] VISA [ ] American Express [ ] Discover

Card #____________________________Exp. Date (M/Y)____________________________

Security / Verification / CVV Code____________________________(Three or four digit code on back or front of credit card.)

Authorizing Signature:____________________________

Social Work Fall Virtual Conference

[ ] $100   Early Bird fee if received by October 16, 2020

[ ] $125    Standard fee if received after October 16, 2020

 

A certificate verifying attendance and contact hours will be issued to all participants.

Note: The University of Alabama is committed to complying with the Americans with Disabilities Act. Requests for accommodation of physical and/or dietary needs should be made at least 30 calendar days in advance of the program date. Please email your request to amandab.bama@ua.edu. A portion of the invoice amount for this program will go to the Capstone Lifelong Learning Foundation to support activities of The University of Alabama and the College of Continuing Studies. Need our STAARS Vendor Number? Please use VC000118827 for UA College of Continuing Studies.

Questions? Contact Amanda Bergeron at 205-348-3300 or email amandab.bama@ua.edu. More information at hrm.ua.edu