|
Chancellor's
Certificate |
University
of Missouri-St. Louis |
Complete the application form below and enclose full payment with registration. Confirmation and map will be mailed on receipt of registration.
By Mail: University of Missouri-St. Louis, West County
Continuing Education Center, 12837 Flushing Meadows Dr., St. Louis, MO 63131
By Phone: Charge with MasterCard, VISA, or Discover
by calling (314) 984-9000
By FAX: (314) 966-0409
For Invoicing: Attach copy of Purchase Order, along with authorization and billing information, including name of person responsible for payment. All documents must have billing address and signature.
| Name ______________________________________________________________________________ |
| Student # (if known) __________________________________________________________________ |
| Employer____________________________________________________________________________ |
|
Address for mailing confirmation: |
Address for billing (if different from address for confirmation): |
| _________________________________________ | _____________________________________________ |
| _________________________________________ | _____________________________________________ |
| City, State, ZIP____________________________ | City, State, ZIP________________________________ |
| Phone: Business__________________________ | Phone: Business______________________________ |
| Phone: Home ____________________________ | Phone: Home_________________________________ |
| Fax_____________________________________ | Fax_________________________________________ |
| E-mail Address___________________________________________________________________________
(to e-mail you a confirmation of your class registration) |
|
| Fill in the course information below: | |
| Course___________________________________ | Course Code _____________________Fee ________ |
| Course___________________________________ | Course Code _____________________Fee ________ |
| Course___________________________________ | Course Code _____________________Fee ________ |
Fees are payable by check or charge. To charge, fill in:
|
MasterCard / VISA
/ Discover # |
||
| Amount Paid________________ | Exp. Date_______ | Signature_________________________________ |
|
|
||