Certified Trainer Program

If you need to pay via Credit Card, please skip this form and Click Here to Register.

Your Name

Address:

Street 1

Street 2

City

State

Zip

Country

Organization/Affiliation

Position

Daytime Phone

Other Phone

Fax (optional)

Email

Distance Learning Experience
(please list)

$695 (includes course materials, access to online classroom and certificate upon graduation).

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.

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
  Murphy Building
  Carrollton, Georgia 30118

Or Call: 678.839.6248 for Help.

Your Name
Address:
Street 1
Street 2
City
State
Zip
Country
Organization/Affiliation
Position
Daytime Phone
Other Phone
Fax (optional)
Email
Distance Learning Experience (please list)