Print and Fax or Mail
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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) 941-7582 · Fax (570) 941-7937 ·
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_____________
&nbs
p;
Authorizing Signature___________________________________________________
¨Please send me more information on:
mPrograms mLab Rentals mOn-Line Courses mOther____________________
How did you find out about this program?
mCPTD website memail mcatalog mnewsletter
mScranton C of C website mUniversity publication mProgram Postcard
mnewspaper: name____________________ mmagazine: name____________________
mweb ad:website name:____________________ mOther____________________