Go to nhnepa.com

 

New Horizons Allentown, Reading,

 

& Wilkes-Barre/Scranton

 

Student Registration Fax Form

 

Fax to: 570-270-2720


1. Student Registration Information

 

Last Name

 

Mailing Address

 

First Name

 

City

 

Title

 

State & Zip Code

 

Company Name

 

Country

 

Office Phone

 

Home Phone

 

Fax Number

 

Email Address

 

 

 Training Consultant’s Name: 

  ________________________________

   r  Check here if you’re a new customer

 

 

2. Course Information

Please enter the dates of the training course you wish to register for:

 

Course Title:

Date & Time:______________

Course Fee: $_____________

Course Title:

Date & Time:______________

Course Fee: $_____________

 

Course Title:

Date & Time:______________

Course Fee: $_____________

 

 

3. Payment Methods

Please check the appropriate box and enter your information:

r Cash

 r Company Check

r Personal Check 

Make checks payable to:   

New Horizons of Wilkes-Barre/Scranton     

r Credit Card

     Credit Card Type:

r Visa

r American Express

r MasterCard

r Discover

Credit Card #

 

Expiration Date

 
Card Holder’s Name

 

Auth. Signature

 

r Coupon

Please bring with you on the first day of the course.

r Club Member

 

To register, please fax or e-mail registration form to:

 

New Horizons Computer Learning Centers of Allentown, Reading, & Wilkes-Barre/Scranton

225 Stewart Road, Hanover Industrial Estates, Wilkes-Barre, PA 18706

Phone (570) 270-2703   Fax (570) 270-2720   E-mail: sales.wilkesbarre@newhorizons.com