INTERNATIONAL INSTITUTE FOR REMINISCENCE AND LIFE REVIEW

The Center For Continuing Education/Extension - University of Wisconsin-Superior

 

Sign up for a year of access to the IIRLR Web site and all we have to offer. Print and fill-out this form, and mail or fax it to us. You will receive a username and password through email as soon as we've received your registration.

Date: ______________________________(mm/dd/yyyy)
Name:
____________________________________________
Address:
____________________________________________
City, State Zip:
________________________, ______ ,____________
Country: ____________________________
Business/Company:
____________________________________________
Daytime Phone Number:
(________) ________ - __________
Evening Phone Number:
(________) ________ - __________
E-Mail Address:
____________________________________________
Social Security Number:
________ - ______ - __________
  (Required only if you will be claiming the education tax deduction)
I'm Enrolling As: Member
Amount Enclosed: $
  Payment Method:
Credit Card: VISA    MASTERCARD    DISCOVER    AMERICAN EXPRESS (Circle One)
Card Number: ______________________________________
Expiration date: ______________________________(mm/dd/yyyy)
Authorized Signature: ______________________________________
- OR -  Check Enclosed: Please make check payable to "UW-SUPERIOR"


 

Fax your registration to:
715-394-8381

Mail your registration to:

University of Wisconsin-Superior
Center for Continuing Education Extension IIRLR
PO Box 2000
Superior WI 54880-4500

  

Copyright 2000 UW-Superior Center for Continuing Education/Extension

Web Site Administrator dsislo@uwsuper.edu