Application for Enrollment - Harley-Davidson

Application for Enrollment
I wish to enroll in the following course:
Police Motorcycle Operator Training $ 1,495.00
Date
City
Police Motorcycle Instructor Training $ 1,795.00
Date
City
Police Motorcycle Instructor Recert. $ 150.00
Date
City
Name and Rank/Title:
Rank/Title:
Mr. Ms.
First Name M.I. Last Name
Personal Information:
Location where you may best be reached: Home Business Office Department Office
Street address at above location:
City, State, Zip:
Phone: ( ) Gender: M F
Email:
Apt/Suite:
Country:
Date of Hire at Current Agency
Billing Information:
Please indicate location where we may send all billing inquiries:
Agency/Business:
Agency Contact: Mr. Ms.
Street address:
City, State, Zip:
Phone: ( ) Fax: ( )
Apt/Suite:
Country:
Payment Information:
Purchase Order # OR Credit Card Type: AMEX MC VISA
Credit Card #:
Exp. Date:
Month
Year
It is the policy of Northwestern University not to discriminate against any individual on the basis of race, color, religion, national
origin, sex, age, or handicap in matters of admissions, employment, housing, or services in the educational programs or activities
which it operates, in accordance with civil rights legislation.
Return to: NUCPS Registrar or FAX to: (847) 467-0540
P.O. Box 1409
Evanston, Il 60204
http://nucps.northwestern.edu