2012 INSTITUTE ONLINE REGISTRATION FORM

To register online for a Collins Institute, please complete and submit the form below. To protect your security, we do not request credit card information online. Upon submission of your registration form, please contact us via phone at 800-932-4477 to provide the information we need to process your credit card payment and complete your registration.

SPECIAL NOTE: This registration form reflects the most current information available about workshop locations and dates. Please note that courses may be added, and occasionally, courses may be canceled.

1. Which Institute do you wish to attend?

Writing and Thinking Across the Curriculum

(The cost of the Institute includes the registration fee plus books and materials.)

2. How did you learn about the Institute?

Website Workshop Mailer Email Other

3. How do you wish to pay the registration fee?

PO Credit Card ** Check

** For security reasons, please call 1-800-932-4477 with your credit card information at your earliest convenience.

4. If you will be using a Purchase Order, what's the PO number?

PO #

Please list the names of all those being registered for the workshop:

6. Billing Contact: * REQUIRED

* Name
* E-mail
* Phone
Fax
School
* Street/PO Box
* City
* State
* Zip

7. Registration & Confirmation Contact: (if different from billing)

Name
E-mail
Phone
Fax
School
Street/PO Box
City
State
Zip

8. Enter any additional comments in the space provided below:

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No portion of the Collins Writing Program^sm or products of Collins Education Associates LLC may be copied without permission.

320 Main Street, PO Box 957, West Newbury, MA 01985

TEL 800-932-4477 FAX 978-363-2212 EMAIL info@collinsed.com