Name
_______________________________________________________________
Address
_____________________________________________________________
City/State/Zip
________________________________________________________
Phone
_______________________________________________________
1st
visit?
_____
Repeat
visit?
_____
Time
_______
Status: ___
UW
Alum.
___
UW
Undergrad.
___
UW
Grad.
Stu.
___
UW
Faculty
___
UW
Staff
___
UW
Extension
Other:
___
precollege
___institutional
___
independent
Institutional/Business
Affiliation
_______________________________________________________________________________________________________________
forms\regpad.doc
02/15/04
spcoll
40
Name
_______________________________________________________________
Address
_____________________________________________________________
City/State/Zip
________________________________________________________
Phone
_______________________________________________________
1st
visit?
_____
Repeat
visit?
_____
Time
_______
Status: ___
UW
Alum.
___
UW
Undergrad.
___
UW
Grad.
Stu.
___
UW
Faculty
___
UW
Staff
___
UW
Extension
Other:
___
precollege
___institutional
___
independent
Institutional/Business
Affiliation
_______________________________________________________________________________________________________________
forms\regpad.doc
02/15/04
spcoll
40
Name
_______________________________________________________________
Address
_____________________________________________________________
City/State/Zip
________________________________________________________
Phone
_______________________________________________________
1st
visit?
_____
Repeat
visit?
_____
Time
_______
Status: ___
UW
Alum.
___
UW
Undergrad.
___
UW
Grad.
Stu.
___
UW
Faculty
___
UW
Staff
___
UW
Extension
Other:
___
precollege
___institutional
___
independent
Institutional/Business
Affiliation
_______________________________________________________________________________________________________________
forms\regpad.doc
02/15/04
spcoll
40
Name
_______________________________________________________________
Address
_____________________________________________________________
City/State/Zip
________________________________________________________
Phone
_______________________________________________________
1st
visit?
_____
Repeat
visit?
_____
Time
_______
Status: ___
UW
Alum.
___
UW
Undergrad.
___
UW
Grad.
Stu.
___
UW
Faculty
___
UW
Staff
___
UW
Extension
Other:
___
precollege
___institutional
___
independent
Institutional/Business
Affiliation
_______________________________________________________________________________________________________________
forms\regpad.doc
02/15/04
spcoll
40
118 · SPEC Kit 296
University of Washington