After filling in the following blanks, a page will be generated that you can then fax or mail to us in order for you to register for your course. If you encounter any problems using this form, please contact our office during normal business hours (EST) at 919.515.2261

PARTICIPANT INFORMATION

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PRIORITY CODE:
NAME:
FULL TITLE:
AGENCY:
ADDRESS:
CITY:
STATE:
ZIP CODE:
WORK PHONE:
FAX:
E-MAIL:
APPROVING MANAGER:
DATE OF BIRTH:	mm/dd/yy (Used for record keeping purposes only)

PROGRAM INFORMATION

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PROGRAM TITLE:	AC21 International Forum
PROGRAM DATE:	Mon, July 28, 2008 - Wed, July 30, 2008
PROGRAM COST:	$250.00 $350.00 $150.00   Choose correct fee
	$250.00 - AC21 Members
	$350.00 - Non-AC21 Members
	$150.00 - Student Registration fees
SECTION ID:	HAC21F09 - HAC21F09

PAYMENT INFORMATION

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All fees must be paid in U.S. Dollars. Please note: the registration process is not completed until payment is received. Without payment you are not registered for the program. Please check the method of payment you wish to use below. Please indicate your preferred method of payment below:

Check Enclosed (for mail in registrations only)
Purchase Order
Credit Card
We accept VISA, MasterCard and American Express

919.515.2261 - NC State University – 1101 Gorman Street – Campus Box 7401 – Raleigh, NC 27695
Office of Professional Development is a unit of the McKimmon Center for Extension & Continuing Education
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