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Online Enrollment Form

Distance Education Certificate Program Enrollment Information
Plan D: Individual Courses, $50 for orientation module. Select up to two courses that you want to enroll in:

Course 1:

Course 2 (optional):

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
21 N. Park St., Room 7247
Madison, WI 53715-1218

Bill me
Bill my organization (type billing instructions and address 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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