MSAD 40 Adult Education
Name__________________________________________Phone___________________________
Address________________________________________Work/Cell______________________
Town__________________State_____Zip_____________E-mail__________________________
For programming purposes, would you help us out, by giving us your year of birth?_________________
If you would like to receive an e-mail update, please note your e-mail address above!
Course Session/Day/Date Fee(s)
1._____________________________________________________ $_____________
2._____________________________________________________ $_____________
3._____________________________________________________ $_____________
Total Amount Enclosed $_____________
We accept Visa and Mastercard credit and debit cards.
Credit Card #___________________________________________________________________
Expiration Date______________________________Code________________________________
Date:_______________________Cash________Check__________Credit________
TOTAL
TOTAL
23
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