Staff

Online Certificate Program for Diversity and Inclusion in Veterinary Medicine

PURDUE UNIVERSITY

25 MEMBER GROUP Registration Form

Workplace Name______

Program Fee: $3,750(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.

Workplace Name______

Group Registrants:

1. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

2. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

3. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

4. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

Workplace Name______

5. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

6. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

7. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

8. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

9. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

Workplace Name______

10. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

11. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

12. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

13. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

14. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

Workplace Name______

15. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

16. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

17. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

18. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

19. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

Workplace Name______

20. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

21. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

22. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

23. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

24. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address

Workplace Name______

25. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

*Email (required)______This is my home  work address