Microcomputer Program - Registration Form

Chancellor’s Certificate
Computer Classes

University of Missouri-St. Louis
Continuing Education
Registration Form

Complete the application form below and enclose full payment with registration. Confirmation and map will be mailed on receipt of registration.

By Mail: University of Missouri–St. Louis, West County Computer Center, 1715 Deer Tracks Trail, Suite 240, St. Louis, MO 63131
By Phone: Charge with MasterCard, VISA, or Discover by calling (314) 984-9000
By FAX: (314) 966-0409

For Invoicing: Attach copy of Purchase Order, along with authorization and billing information, including name of person responsible for payment. All documents must have billing address and signature.

Name ______________________________________________________________________________

Student # (if known) __________________________________________________________________

Employer____________________________________________________________________________

Address for mailing confirmation:	Address for billing (if different from address for confirmation):
_________________________________________	_____________________________________________
_________________________________________	_____________________________________________
City, State, ZIP____________________________	City, State, ZIP________________________________
Phone: Business__________________________	Phone: Business______________________________
Phone: Home ____________________________	Phone: Home_________________________________
Fax_____________________________________	Fax_________________________________________
E-mail Address___________________________________________________________________________ (If you would like to receive announcements of new schedules & e-mailed confirmations)
Fill in the course information below:
Course___________________________________	Course Code _____________________Fee ________
Course___________________________________	Course Code _____________________Fee ________
Course___________________________________	Course Code _____________________Fee ________

Fees are payable by check or charge. To charge, fill in:

MasterCard / VISA / Discover #
____________________________________________________________________________________

Amount Paid________________

Exp. Date_______

Signature_________________________________

Computer Education