UW Extension Registration Form

Please print:
 
  _________________________________________
Name (last) 		_________________________
Name (first) 		___
M.I.
 
  _________________________________________________________________________
Mailing address
 
  ______________________________________________
City 		_________
State 		________________
Zip
 
  ____________________________________
Social Security Number* 		____________________________________
Date of Birth
 
  ____________________________________
(Area code) Daytime phone 		_____________________________________
(Area code) Evening phone
 
  Yes, I wish to register for Illustrating Children's Picture Books (Reg # 93311)
  Workshop fee $489
  Registration fee $35
  ----------
Total fee = $524

  Method of Payment:
  Check in U.S. funds payable to University of Washington. Returned checks are subject to a $25 service fee.
  Third-party payer -- separate document (purchase order or letter of authorization to bill) must accompany this form.
 
  VISA MasterCard
  Note: If paying by VISA or MasterCard, you may also register by phone at 206-897-8939 or 1-800-506-1325.
 
  ___________________________________________________
Card number		 ________________
Expiration date
 
  ____________________________________________________________________
Name as it appears on card
 
  ____________________________________________________________________
Credit card billing address
 
  ____________________________________________________________________
Signature

  Mail completed form to: UW Extension
Registration Services
PO Box 45010
Seattle, WA 98145-0010
 
  Or fax form to: 206-685-9359
 
  * For tax purposes, federal law requires the University to obtain your Social Security Number.