Partner
Workshop Registration
Form
Name_________________________________ Date___________________
(Last Name, First Name, MI; please print clearly; please print clearly
and indicate which of middle and first names you use, by using initial
for non-used.)
Permanent Address_______________________________________________________________
City _______________State________ Zip____________________
Phone Number(s) (h)_______________ (w)________________
E-mail(s) (h)______________ (w)_______________
Soc Sec # ___________________________Date of Birth_________________
Oregon licensed teacher? ___________ If so, what year were you licensed?
__________
Master's degree? __________ Currently in any WU program? _________
If so, which?___________
Currently teaching? __________ If so, what grade(s)? _______________________
Subjects(s)? _________________________ School? ____________________________________
District? _______________________________________________________________________
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before? Y N_______
If yes, and in a program, which one? _________________________________Year(s)?__________
If your name has changed since attending, and you would like your official
transcripts to reflect that change, please call the Registrar's Office
(503-370-6206) or e-mail rkister@willamette.edu.
....................................
Course #: ED 767A Course Title: Physics of Toys Qrtr
Hr: Online Credits: 2 Instructor: Mink
Term(s): ___________________________ (please put Fall
(Sept-Dec), Spring (Jan-May) or Summer (June-Aug) and the year (2004)
...........................................................................................................................................................
Cost: $45 per credit Paid: Y N
Paid with check # _________ OR please charge my credit card $_____________
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Card # _______________________________________________Exp.
Date _________________
NOW REQUIRED BY CASHIER'S OFFICE:
CID # (3-digit code number after card # in signature panel on back of
card) ____________________
Cardholder Name (printed) ________________________________________________________
Signature of Cardholder ___________________________________________________________
Address of Cardholder (if different than above)
______________________________________________________________________________
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