Online Enrollment Form

	About the program
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	Enrollment options
	Group online track
	Self-paced track
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Online Enrollment Form

Distance Education Certificate Program Enrollment Information

Plan A: Course Modules and Standard Electives, $2800 (The orientation module will be sent to you)

Select either Self-paced Learning Track or Collaborative Learning Track below

Plan A-SPT: Self-paced Learning Track
Plan A-CLT: Collaborative Learning Track Fall (October) Group
Plan A-CLT: Collaborative Learning Track Winter (January) Group

Payment Selection
I will pay in full ($2800)
I will pay in installments ($600 initial installment, $440 each month for 5 months)

Payment Method
Credit card - You will be forwarded to the University of Wisconsin-Madison's secured server to complete this transaction.

Check or purchase order (payable in U.S. funds to UW-Madison). Mail to:

Distance Education Professional Development
University of Wisconsin-Madison
225 N. Mills St., Room 110 Teacher Education Bldg.
Madison, WI 53706-1707

Bill me
Bill my organization (type billing instructions and address in the box below)

Other (type billing information in the box below)

Contact information

First name:
Last name:
Title:
Organization:
Address:
City:
State:
Zip/Postal code:
Country:
Phone:
Fax:
E-mail:

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