Please provide the following contact information for our Mailing List and Class Register (you may have to click on the "Submit Form" button more than once to register your information.  If unsuccessful, please e-mail Rose Clemente at rclemente@uaeu.ac.ae):

First Name:
Last Name:
Street Address:
Address (cont.):
City:
State/Province:
Postal Code:
Country:
Contact Phone:
FAX:
E-mail:

Remarks: