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Registration

*Personal Information (= required fields)**
Course Title	Course Location

Course Instructor	Course Hours

Beginning Date: (MM-DD-YY)	Ending Date: (MM-DD-YY)

*Last Name	*First Name

*Department/Agency	Dept./Agency Address

*Dept./Agency Phone Number: (Include Area Code)	Officer’s Contact Number: (Include Area Code)

Contact Us

Hawthorne Center
1801 Windish Drive
Galesburg, IL 61401

Phone: 309/344-3366
FAX: 309/344-5215

email: wiptu@gallatinriver.net


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