Registration - Lessons Of Our Land

CEU Admission/Registration Form

Please neatly print your information below so that we have the correct spelling of your name for documents and data purposes. Thank you! The $100 enrollment fee for Professional Development must be paid in advance and sent to ILTF prior to registration. Questions regarding payment may be directed to: Samantha Manz, Program Officer at Indian Land Tenure Foundation. (email: smanz@iltf.org or telephone 651-766-8999)

Date(Required)

Name(Required)

First Middle Last Former/Maiden(If applicable)

Date of Birth(Required)

Gender(Required)

Male

Female

Section A Contact Information

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Telephone Number(Required)

Work Telephone Number(Required)

Email Address(Required)

Ethnicity(Required)

Native American

African American

Asian/Pacific Islander

Caucasian

Latino or Hispanic

Other

If yes, are you an enrolled member of a Federally Recognized Tribe(Required)

Section B Course/Training Information

CEU Course/Training Title: ILTF-Online Teacher Professional Development Training CEU 308-ZZ 10 hours (1.50CEUs Awarded)

Section C Signature

I have read the above application and answered all questions to the best of my knowledge. Any false information given will be cause for my disqualification for CEUs from UTTC. I agree to abide by the rules and regulations of United Tribes Technical College. I authorize the Office of Extended Learning to solicit information necessary for consideration of qualification for CEUs.

Signature(Required)

United Tribes Technical College does not discriminate on the basis of race, color, national origin, sex, religious preference, age, handicap, marital status, political preference, or membership in an employee organization except as allowed by the Indian preference provision of the Civil Rights Act of 1964, as amended.

Registration Fee(Required)

Price:

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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