Continuing Education Registration Form

Last Name_____________________________ First Name _______________________

Age and Grade(if child) ___________________  Tshirt size (if child)________________

Name of Parents/Guardian (if child)__________________________________________

Company _______________________________________________________________

Mailing Address _________________________________________________________

City _________________________    State _____________  Zip ___________________

Home Phone ______________________  Daytime Phone ________________________

Cell Phone______________________ Email Address____________________________

Course Title _______________________  Course # ____________________________

Fee _________________    Purchase order #___________________

Required for Online Courses:

Course Start Date _____________________

Mail To:

SOSU Continuing Education

1405 N 4th Ave PMB 4232

Durant, OK 74701-0609

Toll-free 1-800-435-1327 ext 2858

Phone #: 580-745-2858

Fax #: 580-745-7462

For Office Use Only

Cash __________    Check __________

V/MC/D/AE Exp Date _________    VIN CODE_________

# ____________________________________________

Date __________ By __________

R  B  R  ML