First Name _____________________________________ MI _____________ First Name ________________________________________________
Title ☐Dr. ☐Prof ☐Ms. ☐Mrs. ☐Mr. First Name _____________________________________ MI _____________ First Name ________________________________________________ Affiliation: _______________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________ (Street/P.O. Box) (City, State, Zip Code) Phone #: ____________________________________________________ Alt. Phone #: ______________________________________________ Email: _______________________________________________________ Website Address: _________________________________________ REGISTRATION FEE: $699.00 (FOR NON-UVI EMPLOYEES) PAYMENT ☐My Check made payable to the University of the Virgin Islands is enclosed. …
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Title ☐Dr. ☐Prof ☐Ms. ☐Mrs. ☐Mr. First Name _____________________________________ MI _____________ First Name ________________________________________________ Affiliation: _______________________________________________________________________________________________________________________ Address: _________________________________________________________________________________________________________________________ (Street/P.O. Box) (City, State, Zip Code) Phone #: ____________________________________________________ Alt. Phone #: ______________________________________________ Email: _______________________________________________________ Website Address: _________________________________________ REGISTRATION FEE: $699.00 (FOR NON-UVI EMPLOYEES) PAYMENT ☐My Check made payable to the University of the Virgin Islands is enclosed. ☐CREDIT CARD: ☐Visa ☐Master Card ☐AMEX Name (as it appears on your credit card) __________________________________________________________________________ Address (if different from above) __________________________________________________________________________________ Credit Card #: ________________________________________________________ Expiration Date: ____________________ Signature: ____________________________________________________________ Date: _________________________________ Please print and complete this form and fax, mail or email to the address below. ~~~ University of the Virgin Islands Center for the Study of Spirituality and Professionalism (CSAP) Office of the President #2 John Brewers Bay ~ St. Thomas, V.I. 00802 (340) 693-1003 (O) / (340) 693-1005 (F) Email: wendy.coram@live.uvi.edu ☐St. Thomas Campus ☐St. Croix Campus UVI Center for the Study of Spirituality and Professionalism (CSAP) PULSE REGISTRATION FORM “CONVERSATIONS FOR CHANGE”