Students at Colleges/Schools of Veterinary Medicine

Online Certificate Program for Diversity and Inclusion in Veterinary Medicine

PURDUE UNIVERSITY

50 MEMBER GROUP Registration Form

Veterinary College/School______

Course Fees: $2500(Please note: Group must have exactly 50 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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

2. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

3. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

4. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

6. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

7. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

8. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

10. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

11. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

12. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

14. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

15. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

16. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

18. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

19. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

20. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

22. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

23. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

24. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

25. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

26. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

27. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

28. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

29. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

30. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

31. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

32. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

33. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

34. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

35. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

36. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

37. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

38. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

39. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

40. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

41. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

42. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

43. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

44. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

45. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

46. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

47. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

48. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

Veterinary College/School______

49. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____

50. Name ______

Address______This is my home  work address

City______State______Zip______

Phone______Fax______

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

 Pre-Vet  Veterinary Medical Student: Year____  Veterinary Technology Student: Year ____