Fall Registration Form

Date:

Please insert today's date

Enrollment:

When do you plan to begin your enrollment?  Check all that Apply.

Enrollment Year:

(Enter 4-digit year. eg: 2019)

Student Status (Check One)

Please select your course(s)
Student Information:

First Name:

Last Name:

e-mail Address (required):

Phone Number:

Please include Area Code in the following format:  (555) 555 5555

Permanent Address:

Street Address 1:

Street Address 2:

City:

Zip Code:

State:

Mailing Address:

Street Address 1:

Street Address 2:

City:

State:

Zip Code:

References

Name three or more persons acquainted with your academic and/or professional experience.  Please include at  three Recommendation Letters.  Please have each reference listed.  Recommendation letters can be e-mailed to info@pocsinstitute.org.  Please have them indicate your name as the student in the letter.

Reference #1:

First Name:

E-Mail:

Street Address 1:

Street Address 2:

Last Name

U.S. Phone Number:

Please include Area Code in the following format:  (555 555 5555)

City:

State:

Zip Code:

Position

Reference #2:

First Name:

E-Mail:

Street Address 1:

Street Address 2:

Last Name

U.S. Phone Number:

Please include Area Code in the following format:  (555 555 5555)

City:

State:

Zip Code:

Position

Reference #3:

First Name:

E-Mail:

Street Address 1:

Street Address 2:

Last Name

U.S. Phone Number:

Please include Area Code in the following format:  (555 555 5555)

City:

State:

Zip Code:

Position

Payment Information:

Each course cost $360.76 USD.  You are not completely registered until the course is paid for.  Online payments include PayPal fees. 

Upon submission of this form, you will be taken to a page where you can pay for your course

Fall Registration 2020

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Address

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175 St. Bridget's Drive

Rochester, New York

14604