Name:

Job Title: Company:

Mailing Address:

City: State: Zip:

Phone: Fax: E-Mail:

Comments or Special Instructions
(IF YOU WILL BE PAYING FOR A REGISTRATION UNDER A DIFFERENT NAME OR REGISTERING FOR MULTIPLE PEOPLE, PLEASE LIST NAMES HERE) :

$75.00 on or before September 3rd, 2010

Mail or fax payment and registration form to: Seward County Community College/Technical School, & Industry, PO 1137, Liberal, 67905-1137; fax 620-417-1179 or phone 620-417-1170; email: reenie.jackson@sccc.eduRegistration

PLEASE SELECT THE 'SUBMIT' BUTTON BELOW TO BE DIRECTED TO THE PAYMENT SCREEN. THIS FORM WILL BE SUBMITTED TO THE REGISTRATION DEPARTMENT AND YOU WILL RECEIVE A CONFIRMATION VIA E-MAIL.

THANK YOU FOR USING OUR ONLINE REGISTRATION FORM!