Registration Form

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Mail to:

Continuing Professional Education Seminars Education and Training Division Center of Alcohol Studies Rutgers, The State University of New Jersey 607 Allison Road, Piscataway, New Jersey 08854-8001 732-445-4317 732-445-3500 (fax)

Name (Last, First, Middle) ______________________________________________________

Address (Street, City, State, Zip Code) __________________________________________________

Home Phone _____________________________

Employer ____________________________________________

Position ____________________________________________

Address (Street, City, State, Zip Code) __________________________________________________

Business Phone ____________________________ Fax No. __________________


Please circle all seminar numbers for which you wish to register:

1	2	3	4	5	6	7	8	9	10	11	12
13	14	15	16	17	18	19	20	21	22	23	24	25

The cost of the seminar is $75.00. Please enclose your non-refundable deposit of $20.00 per seminar (5 or more, $100.00).

__ Check enclosed payable to Rutgers, The State University of New Jersey.

__ Please charge my MasterCard/VISA account for $__________

A/C No. _______________________  Expiration Date ___________

Signature ________________________ Date _________

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For Office Use: Date Application Received ______________
Deposit Paid _____________________ Check/MO/MC/Visa ____________