LEARNING SEMINAR REGISTRATION FORM

                                Capital University Center

                                    809 E. Dakota Ave.

                                     Pierre, SD  57501
                                       (605) 773-2160

TERM:______________  DATE:______________

NAME________________________________________________________________

ADDRESS_____________________________________________________________

CITY, STATE, ZIP________________________________________________________

TELEPHONE (h) ____________ (w) ____________  E-MAIL______________________

                                                                                                                        Total _____________

Form of Payment:  (  ) Check           (  ) Cash        

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OFFICE USE ONLY

                                AP Code____________________ Comments:___________________________________________

Revised 07-2004