(Please use one form per student per module)
(photocopy blank form as often as you wish!)
Module & Section No.________________________
(e.g. "CAT-01-1999B" )
Module title_________________________________________________
(e.g. "Cataloging Overview" )
Module location___________________________
(e.g. "Peterborough")
Your name:__________________________________________________
(lastname, firstname, middle etc.)
Social Security Number [for ID purposes only] (optional)_______________
Date of birth [for ID purposes only] (optional)________________________
Home address:________________________________________________
(street or PO Box, town/city, state, zip code)
Work (Library / Institution)______________________________________
Work address:________________________________________________
(street or PO Box, town/city, state, zip code)
Home phone:_________________________
Personal e-mail:_________________________________
Work phone:_________________________
Work e-mail:____________________________________
Registration procedure
1) Fill out form
2) Attach check/money order for the correct registration fee
(caution - fees vary by course) make check out to "NH State Library"
Call to arrange for other payment methods!
3) Send Form and Payment by US mail or by VAN Delivery to:
Darlene Reinhard
NH State Library
20 Park Street
Concord, NH 03301
(free courses may fax form to 271-6826)
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