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Mail To:
Registration Services

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:____________________________

Location of Workshops:

Bryant Conference Center 240 Paul W. Bryant Drive Tuscaloosa, AL 35401

You edit all of this as needed. Please do not touch the Questions above, those are a snippet meant to ensure the same look (format).

[ ] $50 BSW Standard

MSW Candidates, Dec 17-18, 2019 (Prog. 07-068-19)

[ ] $350 MSW Early Bird (Received by 5/2/19) [ ] $395 MSW Standard (Received After 5/2/19)

NEW! Law Practice Workshop Series

[ ] $345 Attend All Three Workshops ($115 each) [ ] $129 Attend One Single Workshop
[ ] $90 UA Faculty/Staff Rate per Workshop

Select workshop(s) you will attend:

[ ] Forensic Practice and the Family Court System, June 21, 2019 (Prog. 07-069-19)

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