________________________________________________________________
Name
________________________________________________________________
Date of Birth (MM / DD / YYYY)*
________________________________________________________________
Address for shipping materials and test results
(Must be street address, no P.O. boxes)
________________________________________________________________
City, State, Zip Code, Country
________________________________________________________________
Work Phone No. Home Phone No. Fax No.
________________________________________________________________
E-Mail
_____ Please send me e-mail about Georgia Center programs
*Date of Birth is used to confirm name for retrieval of transcript and
issuance of certificate.
________________________________________________________________
Position/Title
COURSE FEE is $195 (payment must be in US Dollars)
To help us properly record your Continuing Education Units, please tell us if you are a:
[] GMA Member
[] ACCG Member
[] Municipal or County Clerk
[] Other
TOTAL $______
Method of Payment
[] Check (payable to The University of Georgia in U.S. dollars)
[] MasterCard [] American Express [] Discover [] Visa
(We will take phone or fax registration with credit cards only.)
___________________________________________________
Card Number
___________________________ _____________
Name on card Expires
This Form May Be Duplicated
FOUR EASY WAYS TO REGISTER
Mail: Human Resources in Local Government #49136
Suite 196 Certificate Programs
Georgia Center for Continuing Education
The University of Georgia
Athens, Georgia 30602-3603
USA
Phone: +1-800-325-2090 or +1-706-542-6692 with a major credit card
Fax: +1-706-542-7537 with a major credit card
Web: http://www.georgiacenter.uga.edu/is/hr/
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