Wilkes University

RTRP and EA Registration Form

To register online for the OTRP and EA classes, please click HERE.

Otherwise, please print and complete this form.

It should be mailed to the Center for Continued Learning at Wilkes University, 84 West South Street, Wilkes-Barre, PA 18766, or FAXed to the Center at 570-408-7912.


First Name __________________________   Last Name _______________________

Address ____________________________________

City ______________________________   State ____   Zip Code __________


Company Name __________________________________________________

Address ____________________________________

City ______________________________   State ____   Zip Code __________

Work Phone _________________   Home Phone ________________

Fax _________________   E-mail _________________

PTIN # ______________________________

Payment Information

Payment Amount     ____

___ Check   ___  Visa    ___  MasterCard   ____ Discover   ____ AMEX


Credit Card Number _______________________________   Expiration Date ________ 

Verification code _________________________   

Signature _______________________________________

Course Information

Seminar Name ______________________________________    Date ___________

©