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Duke Continuing Studies Registration Form
Please read our Cancellation Policies prior to registering.
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| Participant Information |
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| First Name:_________________________________________________________ |
| Last Name:_________________________________________________________ |
| Address:___________________________________________________________ |
| City/State/Zip:_______________________________________________________ |
| Day Phone:(____) _________________Evening Phone:(____)________________ |
| Email:____________________________________________________________ |
| Fax: (______) _______________________ |
| Company: _________________________________________________________ |
| Job Title: __________________________________________________________ |
| How did you hear about us?___________________________________________ |
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| Courses - Include registration fees only. If the course description lists a materials fee "due at beginning of class," do not include it here; give it to your instructor. |
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ID
# |
Course
Title |
Fee |
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_________________________________________ |
$
_________ |
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_________________________________________ |
$
_________ |
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_________________________________________ |
$
_________ |
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_________________________________________ |
$
_________ |
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_________________________________________ |
$
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Code
(if any) ___________________ TOTAL AMOUNT: |
$
_________ |
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| Payment of Fees |
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| Payment by Check: Check # ________ (Payable to Duke University) |
| Payment by MasterCard/Visa |
| Credit Card Billing Information (please print) |
| First Name _____________________Last Name_______________________ |
| Address__________________________________________________________ |
| City/State/Zip_______________________________ Country(if not USA)______ |
| Total Amount $___________ _____MasterCard _____Visa |
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| Card Number _____ _____ _____ _____ Exp.Date ___/____ |
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| Mail payment and form to: |
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Registration - Duke Continuing Studies; Box 90700; Durham NC 27708-0700
Or fax to: 919-681-8235 |
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Mark Your Calendar! Confirmations are sent only by email.
If a course is full, we will contact you.
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