Charles River Public Internet Center

Name:

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Street Address:

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City, State, Zip Code:

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Telephone (daytime) :

(evening)

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Email Address (confirmations will be emailed):

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Signature and Date - I have read and understand the CRPIC policies, including the refund/cancellation policy.

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Course Name:

Section:

Cost:

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Total

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Mail completed registration form & payment to:
Charles River Public Internet Center
P.O. Box 540589, 154 Moody Street, Waltham, MA 02454

Fax-in registration: Fill out registration form and credit card information, and fax to (781) 891-6535.

Payment Method (please mark an X beside method):

___ Check enclosed, payable to Charles River Public Internet Center

Bill credit card: __ Mastercard __Visa __ AMEX

Credit Card Number:

Expiration Date (mm/yy):

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Cardholder Name (as it appears on the credit card):

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Cardholder Signature:

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