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Advanced registration is required.
COURSE #’s: ERD-____________________
COURSE #’s: ERD-____________________
COURSE #’s: ERD-____________________
PARTICIPANT’S NAME: ________________________________________________________
DAYTIME PHONE: _____________________EVENING PHONE: _________________________
ADDRESS: _________________________________________________________________
CITY: ________________________________
STATE: ______________ ZIP: _____________
COURSE DATES: _______________________
COURSE AMOUNT: $_______________ PAYMENT AMOUNT: $__________________________
MASTERCARD VISA
CREDIT CARD#__________________________________ EXP. DATE___________________
SIGNATURE: ________________________________ Date: __________________________
Complete this form & mail or fax to: LBCC– Center for Training and Professional Development, 4901 E. Carson St., W115, Long
Beach, CA 90808
MAKE CHECKS PAYABLE TO: LBCC-Community Education
Ph: 562-938-5051 or Fax: 562-938-5060 |
