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 ____