Request for Program Information and Mailing Lists

Check all boxes that apply and provide additional contact information below

Please send me information about a specific program. I have listed the program title below.

Please add me to the Continuing Nursing Education mailing list. I will checkmark my clinical and practice interest areas below.

I am already on your mail list, but I have updated my contact information below.

I have additional questions or comments. I would like a CE staff member to contact me.

Indicate course or program of interest

Your Name

Title

Credentials

Are you an alumnus of UW-Madison School of Nursing?

Practice Specialty

Employing Agency

Type of facility: Check all that apply

Your preferred mailing address?

What is your phone number?

What is your fax number?

Your e-mail address

*note: Please type carefully and do not use any spaces in the address. Your email address will be used to contact you, if needed, regarding this form and for future UW program announcements. We never sell our lists.

Interest areas (check all that apply):

Comments/Requests

You can also print this form and Fax or mail it to us at:

Fax to: Continuing Education in Nursing, (608) 263-5194

Mail to:Continuing Education in Nursing, University of Wisconsin-Madison School of Nursing, H6/150 Clinical Sciences Center, 600 Highland Avenue Madison, WI 53792-2455