Continuing Professional Education Registration Form Winter/Spring 2018 Please Print Last Name First Middle Initial Occupation License No. Street City/Town State Zip Email (required for notifications) Phone (Home) (Work) Special Needs: Vision Hearing Access Please detail how we can be of assistance Course Title Start Date Program Code Fee TOTAL ENCLOSED Make check or money order (do not mail cash) payable to William James College/CE Mail to: William James College/CE | 1 Wells Avenue | Newton, MA 02459 Upon receipt of registration and payment, William James College will consider your registration confirmed. We will notify you by email if there is a problem with your registration. Payment Method Payment enclosed: Check # Amount $ Bill my institution: P.O.# Name of institution Contact person Contact phone number Please charge my credit card (check appropriate credit card box) Card Number Security Code Expiration Date Signature FOR OFFICE USE ONLY Date Per Paid Notes LVII Register and Pay Online at www.william james.edu/ce