CONTINUING EDUCATION 117 Herald Court, Suite 211 Punta Gorda, FL 33950 Or fax to 941-505-2130
REGISTRATION FORM RENAISSANCE ACADEMY Name: Last
First
MI
Address: Phone number:
Street City __________________________________________
State
Zip
E-Mail Address:
Course Number
Program
Fee
TOTAL REFUND POLICY: Requests for refund received three (3) business days prior to event will be granted. Form of Payment: CASH is no longer accepted. Please use check or any credit card listed below. Thank you Check made payable to Florida Gulf Coast University enclosed and sent to above-listed address I wish to pay by credit card: MasterCard Name on card: Card #
Visa
______________________
Discover
American Express
Relationship to card owner
Exp. Date:____________________________________ Florida Gulf Coast University is an equal opportunity/affirmative action institution.
Register online at http://RegisterRA.fgcu.edu or call 941-505-0130
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