DISTANCE EDUCATION COURSE REGISTRATION
Course being registered:
Course Name
Course Code
Start Date
General Information
Family Name
Given Name
Initials
PO Box or Number and Street
City or Town
Province
Postal Code
Country
Home:
Work:
Fax:
Email Address
Payment:
Cheque
Credit Card
Sponsored
Credit Card:
Don't send credit card information UNLESS you have a secure connection.
Credit Card Number:
Expiry Date:
Card Holder's Name:
Sponsorship
Contact Person:
Phone:
Name of Company or Agency:
Mailing Address:
Title of Authorized Person:
Date:
Help us Serve you Better
Where did you hear about this course?
How would you like to be contacted about future program offerings?
![[help]](help.gif)
![[course outline]](crseoutl.gif)