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E Phone Fax SSN (last 4 digits) Zip Code Birth Date (MM/DD/YYYY) The information on this form is private data, used to identify and locate you, obtain payment. Name, address, and payment method are mandatory. Both course 1 and course 2 are held at: SCSU Welcome Center Course 1: Thursday, November 29, 2012 355 Fifth Avenue South Course 2: Thursday, December 6, 2012 St. Cloud, MN 56301 Course 1 only Course 2 only $149 before 3 p.m. on 11/15/12 Both Course 1 & 2 $149 before 3 p.m. on 11/21.

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