Print Form
Confucius Institute
Registration is required • Registration deadline is one week prior to the start of class.
Name _____________________________________________________________________________________________
Last First Middle
Address ___________________________________________________________________________________________ This is my home work address. City ______________________________________________________________________________________________ State _____________________________________________________ ZIP ___________________________________ Home Phone _______________________________________________ Work Phone _____________________________ E-mail (required) ___________________________________________________________________________________ This is my home work e-mail address. I require auxiliary aids/services due to a disability. Please contact me at the above address.
Course
Chinese Culture Through Films • 6975-09FL-JB Tuesdays, September 15-October 20 • 7-9 p.m. • $150 Elementary Tourism Chinese • 6976-09FL-JB Wednesdays, September 16-October 21, 2009 • 7-9 p.m. • $150
Payment Method Payment is required upon submission of application.
Enclosed is a check made payable to Purdue University. Please charge to my: VISA American Express Discover MasterCard
Card Number ______________________________________________ Expiration Date __________________________ Authorized Signature ________________________________________________________________________________ Printed Name ______________________________________________________________________________________ Please mail with payment to: CEC Business Services Purdue University Stewart Center, Room 110 128 Memorial Mall West Lafayette, IN 47907-2034 (765) 496-6384
or fax with credit card information to:
Please photocopy this form for additional registrants. Purdue University is an equal access/equal opportunity university.