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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 570-408-7912.

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 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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  • Wilkes University |
  • 84 West South Street, Wilkes-Barre, PA 18766 |
  • 1-800-WILKES-U
  • |
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