Name: ______________________________________________

Address: ____________________________________________
___________________________________________________

Phone: ______________________________________________

Fax: ________________________________________________

Email Address: ________________________________________

Social Security #: ______________________________________
^{Confidential- to identify student records only.}

Are you an SCU alumnus? Program/Year: ___________________

For Counseling Psychology and Education Professionals Only: (Circle one)

Clinical Liscense:

MFCC

LCSW

Psychologist

Lisc. #: ___________

State: _______

Credit Requested:

MCEP

MFCC/LCSW

NBCC

General CE hours/units

BRN

Workshop Title

Starting Date

Workshop #

Fees

___________________________________ ____________ _______________ _______________

___________________________________ ____________ _______________ _______________

___________________________________ ____________ _______________ _______________

Payment Information: (Please circle applicable option)

Check

Check #: _________________

Make check payable to:
Santa Clara University

Purchase Order

Print name & phone number of company representative authorizing purchase order.

Name: ___________________

Phone: ___________________________

Credit Card
(Circle One):

VISA

MasterCard

Discover/Novus

Card #: __________________

Expiration Date: ____________________

Signature of Cardholder:____________________________________________

Return this form to:

Space is limited. Register early!

Santa Clara University
Center for Professional Development
Bannan Hall 244
500 El Camino Real
Santa Clara, CA 95053-0201

Confirmation letters and directions/maps will be mailed to registrants.

or fax your registration to: 408/554-4367

For questions and additional information,
please call 408/551-1981.