CONTINUING PROFESSIONAL EDUCATION REGISTRATION FORM
May be reproduced and mailed with payment to: Outreach Non-Credit Registration Office, P.O. Box 410, State College, PA 16804-0410.
May be faxed with credit card payment information to 814-863-2765. Outreach Non-Credit Registration Office phone 814-867-4973.
1. STUDENT INFORMATION - All information is required
Last Name
First Name
MI
Street
Apt #
City
State
Home / Cell phone
Work phone
E-mail
Gender
**Select the appropriate responses regarding your ethnicity
and your race:
1. Is your ethnicity Hispanic/Latino (Cuban, Mexican,
Puerto Rican, South or Central American, or other Spanish
culture or origin)?
□ Yes, Hispanic /Latino
□ No, not Hispanic/Latino
Zip Code
M
F
Birth Date
What is your race? (Select one or more)
□ White
□ American Indian or Alaska Native
□ Black or African American
□ Asian
□ Native Hawaiian or Other Pacific Islander
**Federal law requires that institutions of higher education gather information regarding the ethnicity and race of its students
and employees. Your individual information will be kept strictly confidential. The law only requires institutions to report
aggregate totals for each category.
2. COURSE SELECTION – Please note course prerequisites listed at the end of course descriptions
Course Title
Course #
Section #
Start Date
Fee
$
$
Total Amount Due at Time of Registration
$
3. PAYMENT INFORMATION - Payment is due at time of registration; cash not accepted in person or by mail.
Enclosed is a check or money order for tuition payable to:
The Pennsylvania State University in the amount of - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Circle One: American Express / VISA / Mastercard / Discover Credit Card Number:
Cardholder (print name):
$
Expiration Date:
Cardholder Signature________________________________________ Amount charged to Credit Card - - -
$
Coupon Code: ________________________________
Company billing Mail or fax completed form with a letter of authorization to address or fax number above. The letter must be on
company letterhead referencing the student, course title, and fee; must be signed by the person responsible for payment; and must
include the complete billing address.
Enrollment Confirmation: You will receive an email confirming your registration. Review for accuracy and report any discrepancies
immediately to the Outreach Non-Credit Registration Office at 814-867-4973. Room assignments will be posted in the Lobby of the
Main Building on the first night of class.
Withdrawals/Refunds: If you cannot attend a course you may receive a full refund by notifying the Continuing Professional Education
Office (610-648-3281) before the registration deadline. There are NO refunds once class has begun, including courses scheduled
without complying with prerequisites, or classes missed as a result of illness, personal emergencies or any other event beyond the
University’s control. The University reserves the right to cancel courses owing to insufficient enrollment or other unforeseen
circumstances. Full refunds will be given in these events.
----------------------------------------------------------------------------------------------------------------------------- -----------------------------------*Social Security # or Penn State Student I.D. #
NOTE: *The Social Security number (SSN) you provide for enrollment purposes, or when requesting specific services, will be used by the University to verify your
unique identity for official record keeping and reporting in the Penn State records management system. If you choose not to supply your SSN, certain services- such as
transcripts, enrollment verifications, and tax reporting and financial aid – will not be available to you and Penn State cannot guarantee a complete academic record
for you. Penn State generates a nine-digit ID that will be used as the primary identifier for all day-to-day transactions. A Social Security number must be supplied to
report Act 48 credit(s). PENN STATE IS AN APPROVED ACT 48 PROVIDER. (Form Rev. 6/11/15)