This form may be duplicated for additional registrations. Please print
in ink or type.
Important—To ensure a timely registration, please include complete
information.
_______________________________________________________________________
Last name First name Middle initial Social Security no.
_______________________________________________________________________
Home address (no. and street or box no.)
_______________________________________________________________________
City State ZIP code
(_____)__________________(_____)_______________________________________
Home phone Business phone E-mail Fax
_______________________________________________________________________
Company or organization
_______________________________________________________________________
Business address (no. and street or box no.)
_______________________________________________________________________
City State ZIP code
MAIL COURSE MATERIALS TO (check one): [ _ ] Home address
[ _ ] Business address
METHOD OF PAYMENT
Your payment, in full, must accompany your registration form. Fax or
telephone registrations must be accompanied by credit card payment information.
The Pennsylvania State University Federal ID number is 24-6000376. Total
amount of course:
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[ _ ] $ 991 PA residents
[ _ ] $1,219 PA residents, Great Valley Degree Students
[ _ ] Enclosed is a check payable to Penn State
[ _ ] Bill my organization to the attention of
:__________________________________________
Name Position
(A letter of authorization must accompany this request.)
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[ _ ] Charge the fee I have checked to my:
[ _ ] MasterCard [
_ ] VISA
___________________________________________
Cardholder’s name Cardholder’s
signature
___________________________________________
Charge no.
Exp. Date (mo./yr.)
(Credit card charges cannot be processed without signature
and exp. date.)
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| DEGREE STATUS: |
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[ _ ] Undergraduate
[ _ ] Graduate |
[ _ ] Enrolled in a degree program
[ _ ] Enrolled in a nondegree program
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| I WILL ATTEND (check one): |
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[ _ ] Penn State Berks, Reading
[ _ ] Penn State Erie, The Behrend College, Erie
[ _ ] Penn State Delaware County, Media
[ _ ] Penn State Beaver, Monaca
[ _ ] Penn State Center at Lewistown
[ _ ] Penn State Fayette, Uniontown
[ _ ] Penn State DuBois, DuBois
[ _ ] Penn State University Park, State College
[ _ ] Penn State Wilkes-Barre Northern Tier Center, Towanda |
[ _ ] Central Instructional Support
Center, Harrisburg
[ _ ] Western Instructional Support Center, Gibsonia
[ _ ] Eastern Instructional Support Center, King of Prussia
[ _ ] Intermediate Unit #1, Coal Center
[ _ ] Intermediate Unit #8, Ebensburg
[ _ ] Intermediate Unit #11, McVeytown
[ _ ] Intermediate Unit #16, Lewisburg
[ _ ] Intermediate Unit #19, Archbald
[ _ ] Intermediate Unit #21, Schnecksville |
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SEND REGISTRATION TO:
Wanda Bickle
PSU Outreach Office of Statewide Programs
501 Keller Building
University Park PA 16802-1308
Phone 814-865-9654
Fax: 814-865-2074
E-mail: wqb2@outreach.psu.edu
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