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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