Registration form for online classes

Directions:

Use this form to register by fax or by mail.

Secure online registration is also available.

To register by phone call 608-262-2451. If you have other questions, please call toll-free 877-336-7836.

Refund/ cancellation policy

By Mail
1) Print this page
2) Complete form and mail to: Online Courses, Dept. of Liberal Studies and the Arts,
Attn: Lori O'Neill, Room 714 Lowell Center. 610 Langdon Street, Madison WI 53703. (Make checks payable to UW-Madison)

By Fax
1) Print this page
2) Complete form and fax to 608-262-1694 (Credit card payment only)

UW Code#W60

Name* (Required)	__________________________________________________________
Mailing address:
Line 1	__________________________________________________________
Line 2	__________________________________________________________
City	__________________________________________________________
State	__________ ZIP __________
Country (if not USA)	__________________________________________________________
E-mail * (Required)	__________________________________________________________
Phone w/area code	__________________________________________________________
Class	__________________________________________________________
Class number	__________
Amount charged to credit card	__________
Credit card	MasterCard   Visa   American Express
Credit card number	__________________________________________________________
Expiration date	Month __________ Year __________
Cardholder's name	__________________________________________________________