This form is to be used for credit card payments only. For payment by check, please print this completed form and mail it along with your check to the Continuing Education Office:

AGTS Continuing Education
1435 N. Glenstone Avenue
Springfield, MO 65802

If taking this course for graduate credit, you must fill out the Continuing Education course selection form in addition to this form.

Name:
Address:
Home Phone:
Work Phone:
Fax:
Email:

Registration (Includes scheduled meals):

If registering persons in addition to the name above, please include the names of additional registrants here:
Registration	$ 150 x	# of persons = $
Graduate Credit: $335/ credit hour, 2 or 3 credit hour options. (Conference fee included.)	$30 Required deposit	# of persons = $ [Only if you want Graduate Credit. If taking this course for graduate credit, you must fill out the Continuing Education course selection form in addition to this form. One-third tuition payment required up front.]
Total = $

How do you plan to pay?   Visa    MasterCard   Discover

This form is to be used for credit card payments only. For payment by check, please print this completed form and mail it along with your check to the Continuing Education Office:

AGTS Continuing Education
1435 N. Glenstone Avenue
Springfield, MO 65802

If paying by credit card, complete the following:

Credit Card Number:
Expiration Date:
Verification Code:	What is the verification code?
Name as it appears on credit card:
Daytime phone number:

*Registration fee included in graduate credit tuition. Additional registration information will be requested from those wishing to take the course for graduate credit.

Updated: Tuesday, January 18, 2011 2:35 PM