Rehabilitation Research & Training Center on Blindness & Low Vision

and the

Division of Academic Outreach and Continuing Education

Mississippi State University

Online Registration Form

(Please complete the following information)

Please check which online course you would like to take:
Managing the Randolph-Sheppard Facility: An Introduction to Business Management for New Facility Mangers and & BEP Counselors

Successful Placement of the Older Consumer with Visual Impairment

Full Name

Title/Position

Organization/University

Address

City

State

Zip Code

Telephone Number

Date of Birth

Fax Number

Email Address

Please check if you would like to receive the following credit, if available for that course:
CRC
CEU

Method of payment: If you would like to pay by credit card, please print this form, provide the credit card information and fax it to us. OR, you may call us with the information.
Purchase order #
Visa card # _______________________________
Mastercard card # __________________________
Cardholder's Signature

For further information, please contact:
Patricia Brock
The Division of Academic Outreach & Continuing Education

PHONE: (662) 325-1457 FAX: (662) 325-8666
Email: pbrock@aoce.msstate.edu

Rehabilitation Research & Training Center on Blindness & Low Vision and the Division of Academic Outreach and Continuing Education

Mississippi State University

Online Registration Form

Rehabilitation Research & Training Center on Blindness & Low Vision

and the

Division of Academic Outreach and Continuing Education