Continuing Ed - Group Portal Request

Thank you for your interest in creating a group portal for your organization. In order for us to create this portal for you, we will need some information. If you need assistance or have questions, please contact continuing.education@cuw.edu.

Which describes your Organization?
Organization's Name
Organization's Billing Address Organization's Billing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Contact Information
Your Name Your Name First Last
Your Title
Your Email
Your Phone Number Your Phone Number - ### - ### ####
Enrollment Person

Please designate the enrollment person on your team to register your staff for Continuing Education offerings.
Enrollment Person's Name Enrollment Person's Name First Last
Enrollment Person's Email
Enrollment Person's Address Enrollment Person's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Enrollment Person's Phone Number Enrollment Person's Phone Number - ### - ### ####
Financial Person

Please designate the Finance person who should receive invoices.
Is this person different then the enrollment person?
Financial Person's Name Financial Person's Name First Last
Financial Person's Email
Financial Person's Address Financial Person's Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Financial Person's Phone Financial Person's Phone - ### - ### ####
Requested Offerings & Additional Information

Continuing Ed - Group Portal Request

Continuing Ed - Group Portal Request

Contact Information

Enrollment Person

Financial Person