Continuing Education Center
Georgia Southern University
Registration Form | Call 912.478.5551

Please PRINT and fill out a separate form for each registrant.

Program Name:
_______________________________________________________

Program Number:

_______________________________________________________

Program Fee:
_______________________________________________________

First Name
_______________________________________________________

Middle Initial
_______________________________________________________

Last Name
_______________________________________________________

Title (if applicable)
_______________________________________________________

Company (if applicable)
_______________________________________________________

Street Address
_______________________________________________________

Home
Work

City
_______________________________________________________
State
_______________________________________________________
Zip Code
_______________________________________________________
Daytime Phone
_______________________________________________________
Cell Phone
_______________________________________________________
Evening Phone
_______________________________________________________
FAX Number
_______________________________________________________
E-mail Address
_______________________________________________________
Please exclude me from eblast mailings.

Payment Method (Please Circle)
Personal check

Company check

Cash (in person only)

VISA personal or corporate
Mastercard personal or corporate

Account Number
_______________________________________________________
Expiration Date Number on back of card
_______________________________________________________
Cardholder’s Name
_______________________________________________________

Mail to: Continuing Education Center
Registrations, Georgia Southern University
PO Box 8124, Statesboro, GA 30460-8124

PAYMENT
We accept MasterCard, VISA, checks, money orders or cash (in person only). Make checks payable to:
Georgia Southern University.

SPECIAL ACCOMMODATIONS
For special assistance, please request accommodation needs at least 14 working days in advance of the program.

REFUND POLICY
If you cannot attend, substitutions are encouraged. Be sure to notify the registration desk of any substitutions at 912.478.5551.

A processing fee is changed for all withdrawals. Each program has its own policy regarding the amount of the processing fee and deadlines for requesting a refund. Please refer to the Continuing Education Center website for more information.

Refunds due to withdrawals take 2 - 4 weeks. If payment was made by cash or check, you will receive your refund in the form of a check. If payment was made by a credit card, your account will be credited.

No refunds are given to registrants who fail to withdraw prior to the beginning of a program.

REGISTRATION
By Phone
Call 912.478.5551 and use a credit card.

By Mail
Complete this form and send to address on the bottom of the page.

By Fax
Complete form, copy as needed and send with your credit card number to 912.478.0847.

In Person
Come to the Registration area in the Nessmith-Lane Continuing Education Building.

For Directions and Maps
Please access information online
http://ceps.georgiasouthern.edu/nessmith-lanedirections.html