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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 ________________
School Name ________________________________________________________
Street Address _______________________________________________
City ______________________________ State ____ Zip Code __________
Phone _________________ Fax _________________
Course Number _______________ Description ________________________________
Credit ___ Audit ___
Responsible for Payment _____ School ____Participant
Room and Board
___ Ramada Double Occupancy ___ Ramada Single Occupancy ___ No Housing Needed
___ Hilton Garden Double Occupancy ___ Hilton Garden Single Occupancy
___ Smoking ___ Non-Smoking
___ Breakfast only ___ Lunch only ___ Meal Combination
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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