To register for Center for Professional Development courses, please print out this form, fill it out and fax or mail it to the Center for Professional Development at Boise State University.

Name __________________________________________________

Title ___________________________________________________

Organization_____________________________________________

Mailing Address __________________________________________

_______________________________________________________

City _________________________State _______ Zip ____________

Work phone _____________________________________________

Fax phone _______________________________________________

Email __________________________________________________

Please register me for:

Program Title and Enrollment Fee

______________________________________ $_______________

______________________________________ $_______________

______________________________________ $_______________

______________________________________ $_______________

Total Payment Enclosed $_______________

How did you find out about this class?
□ Brochure/Postcard         □ Newspaper Insert          □  E-mail/Newsletter

Method of payment (payment must be received before your registration is confirmed):
_____ Check enclosed payable to BSU Center for Professional Development
_____ PO enclosed payable to BSU Center for Professional Development
_____ Visa
_____ MasterCard

Credit Card #_______________________________Exp. ________

Name on Card _________________________________________

Signature _____________________________________________

Fax: (208) 426-1300

Mail: BSU Center for Professional Development
1910 University Drive, Boise ID 83725-1660

Call: (208) 426-3861