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Please print and complete this form.
It should be mailed to the Center for Continued Learning at Wilkes University, 84 West South Street, Wilkes-Barre, PA 18766, or FAXed to the Center at 570-408-7846.
First Name __________________________ Last Name _______________________
Address ____________________________________
City ______________________________ State ____ Zip Code __________
Company Name __________________________________________________
Address ____________________________________
City ______________________________ State ____ Zip Code __________
Work Phone _________________ Home Phone ________________
Fax _________________ E-mail _________________
Social Security # ______________________________
Payment Information...
Payment Amount ____$45 _____$50 _____ $135 Nov. 6 State Tax Update
___ Check ___ Visa ___ MasterCard ____ Discover
Credit Card Number _______________________________ Expiration Date ________
3 digit verification code _________________________
Signature _______________________________________
Course Information...
Seminar Name ______________________________________ Date ___________ |
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