First name:
Middle initial:
Last name:
Preferred Name:
D.O.B.:
Rank:
PID#:
Dept:
Mailing Address:
City:
State:
Zip:
E-mail:
Work Phone:
Please check here if your information has changed from your original LCC application.
LCC Graduation Date:
Check the box next to the module you wish to attend:
January 12-16, 2009
Check here
August 24-28, 2009
You will receive a letter confirming your registration approximately 14 days prior to the start of the module. If you have any questions please contact Dara Glotzbach at email: dara@shsu.edu.
Please print out and fax to LEMIT LEMIT fax number: 936-294-3926