ENROLLMENT FORM

Name:                                                                                                                                                                      

Address:                                                                                                                                                                   

City:                                                                                   State:                    ZIP:                                                    

Home Phone:                                                         Business Phone:                                                                           

E-mail Address:                                                                                                                                                         

Organization/Employer:                                                                                                                                              

[ ]  Yes, I am an IUPUI employee. (Call 317-278-7600 for more information.)

[ ] Yes   [ ] No    Do you have a class on campus?

[ ] Yes   [ ] No    Do you need a complimentary parking permit?

(You must check "Yes" box to receive a permit.)

Course Title                                                                            Course Number                          Course Fee

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

                                                                                                                                                                               

Subtotal of Course Fees:        $                                                 

Less Application Discounts:    $                                                 

Total Due:                             $                                                  

Enclose a check or money order payable to IUPUI or complete the credit card information below:

[ ] MasterCard     [ ] Visa    [ ] Discover     [ ] American Express

Credit Card #:                                                            Exp. Date:                        

Signature:                                                                                                         

If you are paying by Discover Card, MasterCard, or Visa, you may enroll by calling 317-278-7600.

Mail the enrollment form to:

IUPUI Community Learning Network
Continuing Studies Noncredit Program
620 Union Drive, Suite 142
Indianapolis, IN 46202-5171

Parking decals are mailed with your confirmation of enrollment. Please allow ten (10) business days following our receipt of your enrollment to receive your confirmation and parking decal.