* Your Full Name:

* Mailing Address:

* City: * State: * Zip:

* Home Phone Number:

Work Phone Number:

Company Name:

Company Address:

Company City:

Company State: Company Zip:

* E-mail Address:

* Credit Course Non-Credit Course

Course Department: No Selection Accounting Aerospace Studies Agricultural Economics Agricultural Education Agricultural Engineering Agricultural Systems Management Animal Anthropology Apparel Architecture Art Biochemistry Biology Botany Business Administration Cereal Science Chemistry Child Development Civil Engineering Classical Languages Communication Mass Communication Speech Communication Computer Science Construction Management Criminal Justice Economics Education Electrical Engineering Engineering General Engineering Technology English Entomology Family Food and Nutrition French Geography Geology German Health, Physial Education History Human Development Humanities Industrial Engineering Interior Design Landscape Architecture Mathematics Mechanical Engineering Medical Technology Microbiology Military Science Music Nursing Pharmaceutical Sciences Pharmacy Practice Philosophy Physics Plant Pathology Plant Sciences Political Science Polymers Psychology Religion Respiratory Therapy Sociology Soil Science Spanish Statistics Theatre Arts University General Veterinary Science Zoology (Credit Courses)

Course Number: (Credit Courses)

* Course Title:

* Course Location:

* Course Date:

Course Time:

I authorize Distance & Continuing Education to cancel my registration for the above course. Any refund is contingent upon University policy.

Signed: