Registration
                                                 Print and Fax or Mail          (click here for PDF version)

Center for Professional Training and Development
Registration Form

Mail to: The University of Scranton
The Center for Professional Training and Development
O'Hara Hall  1st Floor
Scranton, PA  18510-4639
Phone: (570) 941-4838 · Fax (570) 941-7621 · E-Mail: cptd@scranton.edu

Name________________________________________________________ Royal I.D. ______________

Address______________________________________________________

City____________________________State________Zip_______________

Home Phone(   )________________Work Phone (   )________________E-mail__________________

Vehicle Make and Year___________________________License Plate No.______________________

Type of Computer Platform preferred:    ¨ Windows PC   ¨ MAC

1.  Program Name________________________________________________________

            Start Date__________________________ Fee_______________

2.  Program Name________________________________________________________

            Start Date__________________________ Fee_______________

CEU Credit:  ¨ CPE Accounting (State Board of Accounting) - Add $15   ·  ¨   Act 48 - Teachers
If you are registering for the SHRM^© or APICS/CPIM course please provide your membership number______________________________    

AMOUNT ENCLOSED $__________________

Method of Payment

¨Purchase Order (a copy of PO or letter of authorization must be attached)
        Employer________________________________Position/Title____________________________
        Employer Address________________________________________________________________
        City___________________________________State__________Zip________________________
        Employer Phone(   )___________________ Fax (   )_____________________________________

¨Payment Enclosed. (Make checks payable to The University of Scranton, CCE. (No cash please!))

¨Letter of authorization to bill company attached.

¨VISA        ¨MasterCard        Card No._________________________________________Exp.Date_____________
                                                                Authorizing Signature___________________________________________________

¨Please send me more information on:

        mPrograms    mLab Rentals    mOn-Line Courses    mOther____________________