|
Name |
||
|
Address |
||
|
City |
State |
Zip |
|
Phone (day) |
Phone (evening) |
|
|
E-mail Address |
||
|
Course Title |
Fee |
|
|
|
|
|
|
|
|
|
|
Mastercard or Visa (circle one) |
Card # |
|
Exp. Date |
Signature |
|
The University of Wisconsin asks that you voluntarily respond to the questions below. |
||
|
GENDER (circle one) Male Female |
|
|
|
RACE/ETHNICITY (circle one) |
|
|
|
(A) Black (not of Hispanic origin) |
(B) Asian or Pacific Islander |
(C) American Indian or Alaskan Native |
|
(D) Hispanic |
(E) White (Not Hispanic) |
|
|
ARE YOU ENROLLED IN THIS PROGRAM PRIMARILY FOR CAREER PURPOSES? Yes or No |
||
|
OCCUPATION/ORGANIZATION (circle one) |
||
|
(1) Agriculture/Forestry |
(8) Public Administration (Government |
|
|
(2) Education Services |
(9) Retail Trade |
|
|
(3) Engineering, Architecture, Surveying |
(10) Social Recreation, Religious |
|
|
(4) Finance, Insurance, Real Estate |
(11) Transportation, Communications Utilities |
|
|
(5) Health Services (Physical & Mental) |
(12) Wholesale trade |
|
|
(6) Manufacturing |
(13) Other |
|
|
(7) Protective Services (Police, Guards) |
|
|