Wilkes University

Registration Form

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 570-408-7912.

Contact Information

Registrant
First Name __________________________    Last Name __________________________

Street Address _______________________________________________

City ______________________________      State ____      Zip Code __________

Phone _________________      Fax _________________      E-mail _________________

Social Security # ________________      Date of Birth ________________


School Name ________________________________________________________

Street Address _______________________________________________

City ______________________________      State ____      Zip Code __________

Phone _________________      Fax _________________
 

Course Number _______________    Description ________________________________

Credit ___      Audit ___

Responsible for Payment   _____ School      ____Participant

Meal Options

___ Breakfast $26  

 

Payment Information

 ___ 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


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