College for Professional Studies

Personal Information
Name:
Nickname:
Email Address:
Home Phone:
Address:
City:
State:
Zip Code:

Current Employer
Business Name:
Business Phone:
Address:
City:
State:
Zip Code:
Current position:
How long have you held this position?:
Year(s) of management or supervisory experience:
Duties of present position:
How many employees do you supervise?

Education
Highest educational level attained: 12 College: 1 2 3 4 Graduate: 1 2 3 more
Undergraduate major:
Graduate field:

Seminar date you are enrolling for:
What are your major objectives in enrolling in this seminar?
Referred by:

Payment
Payment information: You may pay by check or credit card. Please choose the appropriate option and follow the accompanying instructions. Credit Card Bill me personally Bill my company

The fee for 3-day LTPS is $1095 and includes all seminar materials, continental breakfast, lunch, and refreshment breaks.

Credit card: If paying by credit card, please submit this form and call Kim Raap with your credit card information. You may reach her at 563/441-9950 or toll-free at 800/747-7574. Bill me/Bill company: A bill will be sent either to your home address or your company's address provided above. Please call Kim Raap with any questions.