Diversity Management Certificate - ILR School - Cornell University

(Please copy to register
additional people)
Mail to: ILR Customer Service Center
Cornell University, ILR School, Ives Hall
Ithaca, NY 14853-3901 Fax to: 607-255-9826
Registration
Form
Participant Information
Name ___________________________________________________________________
Title ____________________________________________________________________
Organization _____________________________________________________________
Address ❏ Work ❏
Home _____________________________________________
City ___________________________________ State _________ Zip________________
Office Phone (_______) ___________________ Home Phone (_______) _____________
Fax (_______) ___________________________
E-mail __________________________________________________________________
Student I.D. No. ___ ___ ___ – ___ ___ – ___ ___ ___ ___
(Please enter your Social Security number if you wish to obtain CEUs)
❏ Check here to receive a 15% discount of the registration fee for NYS
government and NYS not-for-profit organizations
❏ Check here if you have previously attended a workshop
Workshop Selection
Course # Course Title Date Location Price
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Total Price $ ____________
DJS1 A B C D E F G H J
Payment Method
Diversity, Inclusion, and EEO Practice | registration Form
Late cancellations/transfers incur a 25% charge. No-shows and cancellations not in
writing incur a 100% charge. Cancellations and transfers must be in writing and
arrive at Cornell 5 business days before the workshop date to avoid a charge.
Signature of Registrant____________________________________________________
Please check one of the below payment methods:
❏ CHECK ENCLOSED, payable to Cornell University ILR, for $ _____________________
LETTER OF CREDIT: ❏ Enclosed ❏ Will follow registration
Will follow registration
PURCHASE ORDER: ❏ Enclosed ❏
CREDIT CARD: ❏ AMEX ❏ Discover ❏ MasterCard ❏ Visa
TYPE OF CREDIT CARD: ❏ Personal ❏ Corporate
Card # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Name as on Card __________________________________ Exp. Date_____________
Signature ________________________________________ Amount $ ____________
❏ INVOICE $________________________ PAYMENT OF BILL IS AUTHORIZED BY:
Payment must be received 7 business days prior to the workshop start date. You may pay by
credit card or check. Please make checks payable to CORNELL UNIVERSITY ILR. If you elect to
be billed, your manager must sign the registration form to authorize payment.
Name of Registrant’s Manager (Type or Print) __________________________________
Title of Registrant’s Manager (Type or Print) ___________________________________
Signature of Approving Manager___________________________________________
(The signing manager accepts the full terms of the cancellation and payment policy above)
SEND INVOICE TO: ❏ Me
❏
Other (Name) ________________________________
Address (if different from above) _____________________________________________
______________________________________________________________________