Simmons GSLIS CE Registration Form

First Name Last Name
Organization Job Title
Address Type HomeWork    
Street1    
Street2    
City    
State    
Zip    
Country (if not U.S.)
Email    
Home Phone Work Phone
   

For each workshop, please enter the title and the applicable Full, Simmons GSLIS alum, or Simmons GSLIS student cost below.
Workshop Title 1 Cost
Workshop Title 2 Cost
Workshop Title 3 Cost
Workshop Title 4 Cost
Payment Method Will send checkCredit CardElectronic Bank PaymentSchool Voucher
Notes

Student Type
If Simmons GSLIS alum, please enter year of graduation

Do you need professional development points (PDPs) used for recertification at theDepartment of Education? For more information, please see here.

PDP Yes
If yes, we will contact you at the end of the workshop to obtain your Social Security Number.
How did you hear about the GSLIS Continuing Education Program?
Direct Mailing of GSLIS CE PostcardGSLIS CE Email/Listserv Announcement GSLIS CE Website Previous Workshop InfoLink Colleague/Word of Mouth Simmons Alumnet Other (please specify below)
If other, please specify: