ONLINE COURSE REGISTRATION FORM

WINTER 2009 GRADUATE COURSE

"Designing an Effective Writing Program"

AMESBURY, MA

STARTS JANUARY 23, 2009

To register online for this course please complete and submit the form below. To protect your security, we do not request credit card information online. Upon submission of your registration form, please contact us via phone at 800-932-4477 to provide the information we need to process your credit card payment and complete your registration. For your convenience you may also register by phone.

1. How did you learn about the course?

Website Workshop Mailer Email Other

2. How do you wish to pay the tuition fee?

PO Credit Card ** Check

** For security reasons, please call 1-800-932-4477 with your credit card information at your earliest convenience.

3. If you will be using a Purchase Order, what's the PO number?

PO #

4. Billing Contact Information: * REQUIRED

* Name
* E-mail
* Phone
Fax
School
* Street/PO Box
* City
* State
* Zip

5. Registrant Information: (if different from billing)

Name
E-mail
Phone
Fax
School
Street/PO Box
City
State
Zip

6. Enter any additional comments/questions in the space provided below:

Collins Education Associates

320 Main Street

PO Box 957

West Newbury, MA 01985

Phone (978) 363.1188

Toll Free (800) 932.4477

Fax (978) 363.2212

Email info@collinseducationassociates.com