INVOICE
CEU REQUEST FORM
(Continuing Education Units)
The following individual certifies that he/she has attended and participated in the FEEDBACK TRAFFIC CONTROL and TRANSPORTRONICS course held in Las Vegas on August 18 - 20, 2009, and is hereby requesting 1.9 CEUs:
PLEASE PRINT
Name______________________________________________________
Address____________________________________________________
City/State/Zip_______________________________________________
Phone (_____)____________________Fax(_____)__________________
Email:______________________________________________________
I certify the above information is true and correct.
_____________________________________________________________
Signature of Conference Official Date
Please mail this form and check or credit card payment in the amount of $35.00 to:
Chris Schearer, Director
UNLV
Division of Educational Outreach
4505 Maryland Parkway
Box 451019
Las Vegas, NV 89154
Checks should be made payable to: UNLV Board of Regents
Credit Card Information: MasterCard, Visa, Discover, Amex (Circle Card Used)
Card #_____________________________________ Exp. Date______________
Name on Card: (Please Print)_____________________________________________________
Signature Authorization__________________________________________________________
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