) homewood suites by hilton downtown dallas, 1025 elm...
TRANSCRIPT
HS University 8245 Tournament Drive
Suite 200 Memphis, TN 38125
Phone (901) 748-0293 Fax (901) 748-0297
Workshop Registration Form To register, please fill out this form and fax to
(901) 748-0297 or email [email protected] Register Now! Seating is limited and classes fill up fast.
Date of Registration: Type of Registration: □ Phone □ Fax □ Mail Contact Name: Agency Name: Agency Address: Phone: Fax: Email: Student’s Name: ___________________________ Email: ______________________ Student’s Name: ___________________________ Email: ______________________ Student’s Name: ___________________________ Email: ______________________ Student’s Name: ___________________________ Email: ______________________ Student’s Name: ___________________________ Email: ______________________ Student’s Name: ___________________________ Email: ______________________ Course Name & Date: Course Location: Course Cost: #Students: Total Cost: Add-ons: $900.00 ERSEA Credential $2000.00 Supervisor Credential $2600.00 License $25.00 CEU Discounts: □ Take 4 (For 4 or more) -$50.00 Payment Options: (Payment is due prior to start date of class) Enclosed is our check made payable to HS University Check Number Please bill my company (PO must be included) PO Number Please Charge my □ VISA □ Master card □ Discover card □ American Express Card No: - - - Expiration Date: / / Security Code: (three digit Code on back of card) Name on Card: Signature: