First Name: Last Name:

Address:

City: State: Zip:

Telephone: County:

How would you like to take this course?

Internet/email - Cost is $40.00 Email address:

Postal Service - Cost is $75.00

Make check payable to: Extension Special

Credit card payment : Master Card Visa

Cardholder's Name:

Cardholder's Signature:

Charge card No. Expiration date (mo./yr.)

Print form and mail to:
Penn State Cooperative Extension
120 W. John Street, Suite 2
Bedford, PA 15522

Credit card information can be mailed or faxed to 814.623.0318

Registration deadline for 2009 is January 26, 2009