Registration Form

Breiseth Hall • (570) 408-5615 (T) • (570) 408-7912 (F) • Email

Please print and complete this AP Summer Institute form. It should be mailed to the Center for Continued Learning, Wilkes University,  84 West South Street Street, Wilkes-Barre, PA 18766, or FAXed to the Center at 570-408-7846.

Contact Information

Registrant
First Name __________________________    Last Name __________________________

Street Address _______________________________________________

City ______________________________      State ____      Zip Code __________

Phone _________________      Fax _________________      E-mail _________________

Social Security # ________________      Date of Birth ________________

Course Number _______________    Description ________________________________

Credit ___      Audit ___

Responsible for Payment   _____ School      ____Participant

___ Breakfast only      ___ Lunch only      ___ Meal Combination

 
___ Check        ___ **Visa     ___ **Mastercard 

Name _____________________________________________________

Street Address _______________________________________________

City ______________________________ State ____ Zip Code __________

**Credit Card Number _____________________________

 3 digit verification code from back of card _________

Expiration Date __________________     Signature ______________________________

Amount Enclosed __________________________  Balance Due ________________________

Responsible for Balance _____ School     _____ Participant