REGISTRATION FORM

Penn State
Wastewater Biology Courses 2007

This form may be duplicated for additional registrations. Please print in ink or type and return to Penn State at least two weeks before course date.
  
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Last name                        First name              Middle initial

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Penn State ID no. or Social Security no.*                    Title


____________________________ [_] Male   [_]Female                                  
Date of Birth (mm/dd/yyyy)
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E-mail address

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Company or organization

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Business mailing address (no. and street or box no.)

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City                     State                ZIP code          Country

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Preferred daytime phone           Home phone               Fax

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Home mailing address (no. and street or box no.)

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City                     State                ZIP code          Country
*The Social Security number (SSN) you provide for enrollment purposes, or when requesting specific services, will be used by the University to verify your identity for official record keeping and reporting. If you choose not to supply your SSN, certain services--such as transcripts, enrollment verification, tax reporting, and financial aid--may not be available to you, and Penn State cannot guarantee a complete academic record for you. Your SSN will be stored in a central system and used only as a primary source to identify you within the Penn State system; the Penn State ID will be used as the primary identifier.

Course Selection

Please preregister as soon as possible!
Early Registration Fee must be received at least three weeks before course date.
Walk-ins (those who have not preregistered) must pay an additional $30.

Method of Payment

Your payment, in full, must accompany your registration form. Fax or telephone registrations must be accompanied by credit card payment information.

[ _ ] Enclosed is a check or money order for the amount indicated, signed and payable to Penn State.

[ _ ] Enclosed is a purchase order or letter of authorization to bill employer or organization.

[ _ ] Charge the fee(s) I have checked above to my 

   [_] American Express [_] Discover [_] MasterCard [_] VISA (including University purchasing card) 
 
   _____________________________________________________________
   Cardholder's name (please print)

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   Cardholder's signature

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   Charge no.

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   Expiration date: (mo./yr.)

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   Cardholder's e-mail

   (Credit card charges cannot be processed without signature and expiration date.)

Are you a Penn State alumna/alumnus? [ _ ] Yes [ _ ] No

SEND TO
Conferences and Institutes Registration
The Pennsylvania State University
Box 108
State College PA 16804
Fax: 814-863-5175