What is your name?

What is your email address?

What is your billing street address?

List city (town), state, and zip code.

What is your cell or home phone number (include area code)?

List whether you want Full Day ($99), Morning Only ($55), or Afternoon Only ($65).

List the names of the courses if taking individual courses ($25 per credit). Color Contact Lenses ($50), Language of Sales ($25), I Can't See ($50), and/or Fitting Contact Lenses ($50).