INFORMATION

Your Name
Address:
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Street 2
City
State	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY US
Zip Code
Country
Organization/Affiliation
Position
Daytime Phone
Other Phone
Fax (optional)
Email
Distance Learning Experience (please list)

FEE

$690 (includes course materials, access to online classroom and certificate upon graduation).

FORM OF PAYMENT

	Purchase Order If Purchase Order, please supply PO# Fax Purchase Order to: (678)839-0636, attn: Dawn Senfeld. Must be received within 24 hours of registration.
	Credit Card (please contact Dawn Senfeld at (678)839-5489 to process card.)
	I will mail a check (drawn on US funds). Please make payable to: University of West Georgia. Mail to:   University of West Georgia,   attn: Dawn Senfeld   Distance & Distributed Education   Honors House   Carrollton, Georgia 30118 Or Call: 678.839.6248 for Help.