TRAINING DEVELOPMENT CERTIFICATE PROGRAM REGISTRATION FORM

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TRAINING & DEVELOPMENT CERTIFICATE PROGRAM REGISTRATION FORM Name Employer Address City State Daytime Phone Evening Phone Emergency Phone E-mail _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________ Zip ________________

(____) _____________________________________________________ (____) _____________________________________________________ (____) _____________________________________________________

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I wish to register for (Choose one):
FA09 – Mississippi Gulf Coast SP10 – Mississippi Gulf Coast

Method of Payment (Choose one): Money Order Check

Company Order Number: ________________

Make checks payable to The University of Southern Mississippi – WLPI

Amount Enclosed $ _________________________________ Do you belong to:
ASTD – BR Chapter ASTD – MS Chapter ASTD – FW Chapter ASTD – NO Chapter ASTD – PC Chapter GCS & TG

Note: It is our goal to make sure this program is accessible to all persons. If you have a special physical need, please let us know here. _________________________________________________________________________________ __________________________________________________________________________________
Mail to: The University of Southern Mississippi Jack and Patti Phillips Workplace Learning and Performance Institute 730 East Beach Blvd. Long Beach MS 39560 Attention: Suzy Knight Phone: 228.214.3517 Fax: 228.214.3515
AA/EOE/ADAI