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PIONEER TEACHER CENTER and PIONEER DISTRICT

COURSE REGISTRATION FORM

Name_________________________________________ Building______________________________

Home Address________________________________________________________________________

___________________________________________________________________________________

Home Phone_________________________ School/Work Phone________________________________

Course Title_____________________________________ Course dates __________________________

Fee enclosed____________________ (Payable to PIONEER TEACHER CENTER)

Inservice Credit: Yes ( ) No ( ) Number of hours _______________________

Please attach your registration fee and return to:

PIONEER TEACHER CENTER

P. O. BOX 619, Yorkshire, NY 14173

(Telephone: 492-9386)

A SEPARATE CHECK IS REQUIRED FOR EACH COURSE REGISTRATION