Please make a $10.00 check payable to the University of Maine

University of Maine
Continuing Education Unit
Program Completion Form
 

Section 1: (To be completed by Participant)

NOTE:  All items MUST be completed to receive a transcript.

Social Security # Phone#

E-Mail

Name (Last, First, M.I.) 

Date of Birth

Address:

Section 2: (To be completed by Conference Services Office)

Program No:   526*04

Program Title:  TEACHING HISTORY IN MAINE: Maine and New England: Public Images/Invented Traditions

Date:  OCTOBER 26, 2007

Approval granted for:   0.6 CEU credits

Section 3:  (To be completed by Program Instructor)

Eavluation of Participation Program Completion:  Satisfactory

If Unsatisfactory - Why?              N/A               

Instructor's Signature:             Howard Segal               Date:_____________
                                                    

NOTE: The Program Instructor should have each participant complete Section 1 of this form.  At the conclusion of the program activity, the instructor should complete Section 3, sign, and date.  Participants should then return their form along with a $10.00 check (PLEASE NOTE INCREASE IN FEE) made payable to the University of Maine.  Return form by ELECTRONIC SUBMISSION or by mail to Suzanne Moulton, History Department, University of Maine, 5774 Stevens Hall, Orono, ME  04469-5774.  Checks should be made payable to "University of Maine" and sent to the address above.

TO SUBMIT FORM, PLEASE CLICK ON "SUBMIT" BUTTON BELOW: