Registration form for UW Certificate Program
Popular Fiction I Winter Intensive 2010 (Program ID# 3077)

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View program description

To register for the 2010 Popular Fiction I Certificate Program (Winter Intensive), please print, complete and mail this form with your payment to the address below.

(If paying with VISA or MasterCard, you may register by phone at 206-897-8939 or 1-800-506-1325, or by faxing this form to 206-685-9359.)

Open Enrollment Process: To register, please complete and submit this form. You are considered a certificate program student upon registering. Students are registered on a first-come, first-served basis until the program reaches its enrollment limit, or until 5 p.m. on the first day of class.

I wish to register for:
Popular Fiction I Winter Intensive (Registration #102026)	$1,857
Nonrefundable registration fee	$35
Nonrefundable certificate program fee	$50
Total enclosed	$1,942

Mr.    Ms.
Last name:
First name/middle initial:
Social Security # (required):
Date of birth:
Mailing address:
City/State/Zip:
Daytime phone:
E-mail address:

Method of payment:

	Check in U.S. funds made payable to the University of Washington. (Returned checks are subject to a $25 service fee.)
	Third-party payer: separate document (purchase order or letter of authorization to bill) must accompany this form.
	VISA
	MasterCard

Card number:
Expiration date:
Name as it appears on card:
Credit card billing address:
City/State/ZIP
Signature: