Iowa Valley Continuing Education - Course Registration Form

IVCE Course Registration

Name (full legal name)
Last First Mi

Preferred First/Nickname Maiden/Former Last Names(s)

E-mail address

Home Mailing Address
Street
City State Zip

Home Phone Work Phone

Course Information

Course Title: Course Number:

Course Title:Course Number:

How did you find out about the course(s)?

Other

Have you taken a class with us in the past? Yes No

Birth Date (mm/dd/yyyy) or Social Security Number

Do you need continuing education hours or units for relicensure? Yes No

What is your profession?
Professional License/Certification Number

Payment is required prior to the course start date. Payment Method (Select 1)

> Check: Mail all checks (payable to IVCCD) to:

Iowa Valley Continuing Education
3702 South Center St.
Marshalltown, IA 50158

To ensure accuracy please write the course number(s) and the individual you are paying for in the memo section of your check.

Credit Card:Credit card payments must be made in person or over the telephone. Call (641) 752-4645 or (800) 284-4823. DISCOVER/MasterCard/Visa accepted.

Third Party Payment
Name of Employer/Agency
Street
City State Zip
Purchase Order Number

Additional comments?

Before you submit this form print a copy to keep for your records.

3702 S. Center St., Marshalltown, IA 50158 • Ph: 1-800-284-4823 • E: ivceinfo@iavalley.edu