DUHS Education Services Printable Registration

Our online registration process is being revised. Please print this form and mail or fax it to the address below.

Registration
Education Services
Duke University Health System

This form can be printed and used to register for courses:
Please mail (check/money order) or mail/fax (credit card) this form to:

Registration
Box 2722
Duke Unversity Medical Center
Durham, NC 27710
Fax: (919)-681-6251

Name:	RN/LPN/Other:
Address	City/State/Zip
Institution
Unit	Box#
Phone (home)	Phone (business)
Duke UniqueID #
Program Selection
Name of Workshop 1		Date/Session/Time
Name of Workshop 2		Date/Session/Time
Name of Workshop 3		Date/Session/Time
Method of Payment
Check one: Check/money order payable to Hospital Education in the amount of .......... $ __________ MasterCard or VISA in the amount of ............................................. $ __________ Account Number _____________________________________________ Expiration Date ______________________________________________ Name of Card _______________________________________________ Signature as it Appears on Card _________________________________ Check or money order should be made payable to Hospital Education. Mail or fax (credit card only) entire registration form to: Registration Box 2722 Duke University Medical Center Durham, NC 27710 Fax: (919)-681-6251

Last updated: July 1, 2005

Site Created and Maintained by the department of
Education Services

educate@mc.duke.edu