Program # In-Person: CS-2507-HCWF01-01

Program # Online: CS-2507-HCWFV1-01

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Mail To:
Registration Services
The University of Alabama
Box 870388
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:____________________________

Registration Fee:

[  ] $35.00 IN-Person Attendance Preference

[  ] $35.00 Online Attendance Preference

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 professionaldevelopment@ua.edu.

Need our STAARS Vendor Number? Please use VC000118827 for UA Office of Teaching Innovation and Digital Education.

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 Office of Teaching Innovation and Digital Education.

Questions? Contact Doreena Mink at professionaldevelopment@ua.edu.