Registration: Measuring Program Outcomes- February 13, 20, 27 & March 20, 2009
Please complete and return along with payment to MSUM Continuing Studies,
P.O. Box 82, Moorhead, MN 56563
Participant's Full Name (s) __________________________________________
MSUM ID(s) or SS#(s)_____________________________________________
Email (s) ________________________________________________________
Participant's Full Name (s)
__________________________________________
MSUM ID(s) or SS#(s)_____________________________________________
Email (s) ________________________________________________________
Company _____________________________________________________
Address _______________________________________________________
City _______________________ State ________ Zip Code _____________
Phone ___________________Cell ___________________
Email __________________________________________
Payment Method:
Registration Fee: $300 (up to four participants per agency)
(Check One)
[ ] Bill my company. Purchase order # __________________
[ ] Check [ ] Credit Card (Circle One) Visa or MasterCard or Discover
__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Exp __ / __
Name of Card Holder Signature of
Card Holder
_____________________________
_________________________________
For questions or additional information, please call Kathleen Paulson at MSUM Continuing Studies at 218.477.5051 or paulsonk@mnstate.edu
MSU Moorhead is
An Equal Opportunity
Educator and Employer
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