Register for the Statesboro Seminar
Use this form to register for the Statesboro
Seminar on 10/15/13
Name:
License No. or SSN:
Address:
Phone No.
City:
Fax No.
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
VI
WA
WV
WI
WY
E-mail Address:
Zip Code:
Company Name:
If you need credit for NC enter the last four of SSN:
Pay at Door
Mail Check
Invoice
Comments
Printable Form
J & W Educational Services
1340 Hickory Hill Dr.
Watkinsville, Ga 30677
(706) 769-7112
5032 Northshore Court
Conyers, Ga 30094
(770) 922-7086
E-Mail JandW@uga.edu
Sponsored by UGA