University of Montevallo - Department of Continuing Education

Department of Continuing Education

Online Registration Form

(One Class Per Form Please)

I would like to register for the following class through the Department of Continuing Education:

Course Title: Required

Course Number: Required

Registration Fee: Required

Method of Payment: check only one of the following boxes

I will pay with a check at the first class.
I will write a check and mail it
if you are using this last method of payment, fill out this form, print it using the Print command in your browser and send the printed copy with the check to:

University of Montevallo - Business Office
Department of Continuing Education Registration
Station 6060
Montevallo, AL 35115
ATTN: Ms. Susan Hayes
Comptroller

Personal Contact Information: complete all required boxes

Name: Required
Address: Required
City, State: Required
Zip Code: Required	Telephone: Required
Telephone 2:	Telephone 3:
Email: Required
Company Name: (if applicable)
Company Address: (if applicable)
City, State: (if applicable)
Zip Code: (if applicable)	Telephone: (if applicable)
Birth Date: (requested for demographic analysis of our services)
Gender: (requested for demographic analysis of our services) Female Male
When did you last take a UM Continuing Education Course? Last Term Within Past 2 Years More than 2 Years Ago Never
How did you hear about UM Continuing Education? (please check all that apply) Brochure in Mail Newspaper Radio Television Friend At Work Website Other (please specify)

Department of Continuing Education

Online Registration Form

Course Title: Required

Course Number: Required

Registration Fee: Required

Name: Required

Address: Required

City, State: Required

Zip Code: Required

Telephone: Required

Telephone 2:

Telephone 3:

Email: Required

Company Name: (if applicable)

Company Address: (if applicable)

City, State: (if applicable)

Zip Code: (if applicable)

Telephone: (if applicable)

Birth Date: (requested for demographic analysis of our services)