Course Registration Form REGISTRATION IS EASY Course Registration Member Information Please use black ink. Print clearly. Each member must use a separate form. Name
Today’s Date
Social Security Number
Date of Birth
/
/
Home Address City
State
Zip Code
Telephone (Day)
(Evening)
Course Information Course Name SAMPLE: Criminology
Start Date
CRN #
8/30/05
17339
Cost
(Silver Members Only)
Gold and Gold Plus One Members: There is no cost to register for any course in this catalog. Silver Members: Cost to register for a credit course for audit is $100. Costs for other courses are listed in this schedule. Silver members who upgrade to Gold or Gold Plus One can save on course fees. See page 4 of the schedule for more details.
Payment Information FOR SILVER MEMBERS ONLY. Your payment MUST accompany this form. Check. Please enclose check made payable to University of Richmond. When paying by check, payment of membership application and course registration MUST be submitted on separate checks. Credit Card. We accept VISA, MasterCard or American Express. Please complete the following: Please charge my: VISA MasterCard American Express Account Number Card Verification Number
Expiration Date Cardholder’s Name
The card verification number is required to process your payment. This number follows the card number written on the signature strip on the back of the card. On American Express cards, the number is on the front of the card.
Signature
Amount to be Charged $
Please mail or fax your application to us: Registration and Operations Coordinator Office of Community and Professional Education School of Continuing Studies University of Richmond, VA 23173 FAX: (804) 484-1585
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Osher Lifelong Learning Institute • Schedule of Fall 2005 Schedule of Classes