Course Registration Form

Student Information

First Name________________________________Last Name_________________________________________

Student E-mail___________________________Phone__(        )________________________________________

Parent E-mail_______________________________________________________________________________

Address___________________________________________________________________________________

City__________________________________State/Provence_________________Zip/Postal Code___________

Graduation Year ___Freshman ('11)    ___Sophomore ('10)  ___Junior ('09)  ___Senior ('08) Other_______________

Shipping Address (if different from above-we cannot mail to a P.O. Box):

  Address__________________________________________________________________________________

  City_________________________________State/Provence_________________Zip/Postal Code___________

Payment information:

1. Name: _____________________________________________________________________

2. Price:       $499.00                     Ender class code (if applicable)  ACSL7004

   ___I have enclosed a check or money order.     ___Please bill my credit card.

    (Checks made payable to KAPLAN TEST PREP)

Credit Card Number:_________________________________  Expiration Date: ___  ___/___  ___

                             (AmEx/Discover/MC/Visa)

Name on Card:_________________________ Signature of Cardholder_________________________________

Please mail or fax this form to:

Kaplan Test Prep and Admissions

8448 Delmar Blvd.

St. Louis, MO  63124

Phone:  314-997-7791       Fax:  314-997-7368

-OR-

See Julia Daniels in the Guidance Office