Rohrer College of Business

Program Registration

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*Fields marked by an asterisk must be filled in.
Billing Address
*First Name

*Last Name

*Job Title

*Company/Organization

*Address

*City

*State

*Zip Code

Note: A confirmation letter and directions to the training site will be sent to your billing address unless a mailing address is provided.

Mailing Address

Mailing Address
(If different from billing address)

City

State

Zip Code

Contact Information

*Company Phone

Home Phone

*E-Mail Address

*Fax No.

Program Information

* Program Title

* Program Date

Program Location

Program Code

Additional Information

SHRM/Tri-State/HRA member:

Payment Type

*Method of Payment

Payment in Mail
Bill My Company
Bill Me Amount     $
Credit Card
There is no charge for this program

Credit Card Information

Card Type

Visa
MasterCard
American Express

Account No.

Exp. Date

Cardholder’s Name