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FAX
Registration Form:
If you do not wish to preregister on-line, you may want to print the following form. First, turn on your printer and then click on the "print" icon on your browser's menu bar. Before printing, you may also want to increase the size of characters being displayed so that the form will print with a size font that will make it easy for you to read and complete the form.
Course(s) being preregistered for and the desired credit option:
Name: ___________________________________________________
Number: ITJ:__________;
Audit : $75.00;
CEU: $________
Credit: $ ________
Subtotal: $ ___________
Name: ___________________________________________________
Number: ITJ:__________;
Audit: $75.00;
CEU: $________;
Credit:$ _______;
Subtotal: $ ___________
Total Tuition: $________
Select the type of Credit Card you wish to use:
____Master Card; ____Visa; ____American Express.
Card Number:_____________________________________
Expiration Date:____/_____
Name on the Credit Card:
________________________________________________
Social Security Number:
________________________________________________
(Your Social Security number will be used to verify requests for changes to your records and when transcripts are requested.) If you are pre-registering from a country other than the United States, please use another unique number.
Complete items below this line if you are new to ITJ or
if your contact information has changed. If you have taken other ITJ courses and
your information is current, you may stop here and fax this page.
Ms._____; Miss______; Mrs.______; Mr.______:
Last Name ________________________________
First Name ________________________________; Initial ________
Street_____________________________________________________
City_____________________________ State_____ ZIP____________
Country_________________________
Email Address(es):
Home____________________________________________________
Work____________________________________________________
Personal or School WWW Home Page:
http://____________________________________________________
Phone: Home____________________ Work_____________________
Fax: Home _____________________ Work _____________________
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PROFESSIONAL BACKGROUND
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Occupation: ___Teacher ___Administrator ___Student ___Other
(If other, Specify_____________________________________)
Specialty: _________________________________________________
If you are a teacher, which level(s) do you teach?
___Elementary ___Middle School ___High School
___Other (Specify____________________________________)
School's Name & District:
__________________________________________________________
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TECHNOLOGY YOU USE TO ACCESS THE INTERNET
(check all items that apply)
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HARDWARE USED:
Home: ___PC Windows 3.1; ___PC Windows 95;
___Mac (Model _________________)
___Other (Specify___________________________________)
School: ___PC Windows 3.1; ___PC Windows 95;
___Mac (Model _________________)
___Other (Specify___________________________________)
Internet Access Via:
Home: ___Modem (Baud Rate____________)
School: ___Direct via LAN; ___Modem (Baud Rate____________)
SOFTWARE USED:
Home: Email Program_______________________________________
HOME Web Browser :
Netscape version: ____2.01 or 2.02; ____3.0; or ___3.01 or ___3.02
Microsoft IE version: ____ 2.0; ____ 3.0; or ____3.01 or ___3.02
OTHER: __________________________________
School: Email Program_______________________________________
SCHOOL Web Browser:
Netscape version: ____2.01 or 2.02; ____3.0; or ___3.01
Microsoft IE version: ____ 2.0; ____ 3.0; or ____3.01
OTHER: __________________________________
How Did You Hear About the Institute for Teaching Japanese:
___ ITJ brochure; ___NEA Today
___Other journal/newsletter; ___ListServs/Newsgroup
___School/District Email; ___Colleague/Friend
___Conference/Presenter; ___ITJ Email to Educators
___State/Association Web Site/Bulletin Board
___ World Wide Web Search result.
___Other (please specify___________________________________)
