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Mail To: Email to:
Registration Services email@example.com
The University of Alabama
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:____________________________
[ ] 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.)
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 firstname.lastname@example.org. 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.