Course Registration

Registration Form

Please provide the following information about yourself:

First Name
Last Name
License No. (if applicable)
Employer
Title
Street
City
State
Country (if not in USA)
Zip Code
Home Phone
Work Phone
Fax Number
E-mail address

Job Category:	Employer Category:
Industrial Hygiene Medicine Safety Nursing Other (please specify):	Private Industry Federal Government State Government Local Government Academic Foreign Country Union Other (please specify):

Ethnicity:

African-American
Hispanic/Latino
Asian/Pacific Islander
Native American
White/Euro-American
Other (please specify):

Course Information

Course Title	Start Date (00/00/00)	Price




Total

Registration Cancellation Policy: Written cancellation notification (via email or fax) must be received no later than three weeks before the start date of the class in which you are registered, in order to qualify for a refund, less a $50.00 administrative fee. Substitute attendees are welcome.

Transfer Policy: There is no tuition refund within one week of the start date of a class. You can transfer your registration and payment to a later class one (1) time with no penalty. A second transfer will incur a $50.00 administrative fee. We do not allow more than two (2) transfers.

Class Cancellation Policy: In the unlikely event that a class must be cancelled, the entire submitted registration fee will be refunded without further liability on the part of COEH.

Check this box if you would like to receive mail about COEH Continuing Education Courses.

Payment Method

Check by mail.
*Please make all checks out to "UC Regents."* Checks must be sent two weeks before the class start date. Our Federal Tax ID # is 94-6002123.
Purchase Order Please Fax Copy of Purchase Order to 510-643-7291 Intercampus Charge Please call CE Program at (510) 643-7277 to set up this form of payment. Thank you.
Credit Card - We accept Visa, MasterCard (We cannot take your credit card information on the website at this time, and this information should not be e-mailed). You can give us your credit card information three ways:
Phone	Phone Contact: Please provide a contact phone number so that we can call you to process your credit card.
Fax	Please fax the following credit card information, between the hours of 7:30 am - 4:30 pm PT, to: 510-643-7291
Mail	Or Mail the following credit card information to: COEH Continuing Education Program UC Berkeley M/C 5120 2223 Fulton St., 2nd Floor Berkeley, CA 94720-5120
Here’s what we need to process your credit card payment - (1) Type of card - Visa or MasterCard (2) Full name as it appears on the card (3) Credit card account number (4) Expiration date (5) Billing address associated with the card

Web Master/Designer: Gene Darling Labor Occupational Health Program Last Updated May 20, 2008	Home \| Courses \| Asbestos & Lead \| Summer Institute \| Registration Mailing List \| Calendar \| Contact Us \| Links \| COEH \| LOHP
	©2008 University of California, Berkeley School of Public Health - COEH Continuing Education