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Please PRINT form and Fax: (516) 299-2066 or Mail: Office of Continuing Education, C.W. Post Campus, 720 Northern Blvd., Brookville, N.Y. 11548-1300.

Social Security Number

Sex

Last Name First Name M.I.

Mailing Address

 City  State  Country  Zip
     

Home Phone Business Phone

Have you previously attended C.W. Post Yes No

(If so, when? Term Fall Spring Summer Year )

REG. USE ONLY

COURSE NUMBER (As listed in Schedule)

NAME OF COURSE

TUITION

Discipline
(letter code)

Course
(number)

Section
(number)

           
           
           
           

TOTAL

 

Continuing Education Charging Stub

FOR CHARGES ONLY (Please charge the above amount to my credit card)

Name of Cardholder

Signature of Cardholder

Discover (16 digits)
Visa (13 or 16 digits)
Mastercard (16 digits)
Expiration Date (Month/Year)