WorkWORLD Training Programs Registration Form

	WorkWORLD^TM Training
esi@vcu.edu

			Registration Form for WorkWORLD^TM Training Programs

Please read the Registration Details Page before you register.

Print, complete and return with check or agency purchase order to cover registration fee by the dates of the training program for which you are registering. Use a separate form for each attendee. Send to:

Virginia Commonwealth University
Employment Support Institute
School of Business
1015 Floyd Avenue, Room 4158
PO Box 844000
Richmond, VA 23284-4000
Attn: Jim Troxell / Training Registration

You may e-mail or fax the registration form to Jim Troxell at jltroxel@vcu.edu or (804) 828-8884 (for fees paid by agency purchase order only -- PO number must appear on the registration form).

Specify dates of the training program you wish to attend: _________


Name:	____________________________________

Agency Name:	____________________________________
Address 1:	____________________________________
Address 2:	____________________________________
City:	____________________________________
State:	____________________________________
Zip Code:	___________________

Phone:	___________________
E-mail address:	___________________

Fee (indicate amount enclosed):	$__________________

Payment	___Check
Method:	___Purchase Order #__________________

Please provide a specific description of any special accommodations you may require to participate in the training program: _______________________________________________ _______________________________________________ _______________________________________________

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