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 that you first attended the Institute 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 one person acquainted with your academic and/or professional experience.  Please include at least three Recommendation Letters.  Recommendation letters can be e-mailed to info@pocsinstitute.org.  Please have them indicate your name as the student in the letter. 

**If you have already completed this step in a prior semester please continue to submit your registration

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

I certify that my responses are true and correct 
Payment Information:

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

Upon submission of this form, you will be taken to a page where you can make your payments

Fall Registration 2021