Faculty and Faculty Administrators at Colleges/Schools of Veterinary Medicine
Online Certificate Program for Diversity and Inclusion in Veterinary Medicine
PURDUE UNIVERSITY
25 MEMBER GROUP Registration Form
Veterinary College/School______
Program Fee: $5625(Please note: Group must have exactly 25 people)
Payment Method
Enclosed is a check made payable to Purdue University.
I will be paying with a company purchase order. A hard copy must be provided.
P.O. # ______
For credit card payments, please provide a phone number, so we may contact you for your credit card information.
Phone Number:______
Please mail completed form and Group Registrant List with payment to:
Digital Education Business Services
Purdue University
Stewart Center, Room 110
128 Memorial Mall
West Lafayette, IN 47907-2034
For registration information, contact: Valerie Hardy at (765) 494-6315 or Wendy Mouser (765) 496-5172
Purdue University is an equal access/equal opportunity university.
Veterinary College/School______
Group Registrants:
1. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
2. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
3. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
4. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
Veterinary College/School______
5. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
6. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
7. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
8. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
Veterinary College/School______
9. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
10. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
11. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
12. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
Veterinary College/School______
13. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
14. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
15. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
16. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
Veterinary College/School______
17. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
18. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
19. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
20. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
Veterinary College/School______
21. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
22. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
23. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
24. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.
25. Name ______
Address______This is my home work address
City______State______Zip______
Phone______Fax______
*Email (required)______This is my home work address
I am a faculty member. I am an administrator.