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Professional Development Program

* indicates required fields.
*Last Name:    *First Name:    Middle Initial: *E-mail Address:
*Street:   *City:   *County:   *State:   *Zip:
*Home Phone:   Work Phone:   Cell Phone:  
Place of Employment/District:   Type your name here for your *Signature:   Date: 11/26/2015

*Educational Level:
Bachelor from Madonna University Bachelor from another institution Master's and/or Doctorate   Credits earned from Madonna:
*Enrollment Status: New Student  Returning Student
**Ethnic/Racial Group: White, Non-Hispanic  Hispanic  Black, Non-Hispanic  American Indian  Asian or Pacific Islander
*Citizenship: United States  Resident Alien  Non-Immigrant Alien - specify country:
*Date of Birth (month/date/year):   *Place of Birth (state/country):   **Sex: Male   Female  **Religion (specify):   **Marital Status: Married  Single 
** For statistical purposes only. Responses are not required but would be much appreciated.

Registration Period

Please register within two weeks of beginning the professional development training. You may register ahead of time for any anticipated professional development that you plan to attend in the upcoming months. However, hours accrued prior to two weeks before the date that registration is submitted will not be counted.
IMPORTANT: Social Security # is required if student will request tax form 1098T.

* Social Security Number:

Tuition Rate: $150.00 per credit (Pay in full, Non-refundable)
Total number of graduate credits:
Total Tuition (150 times # credits): $0
Please make payment by Master Card, American Express, Discover, Diner's Club or electronic check.
Preferred Course Number:
Preferred Course Name:

# of Credits:
Additional Course Number:

# of Credits:
*Method of Payment:

(PDP Tuition
is Non-Refundable)
Credit Card (NO VISA)   E-Check (No Service Fee)

     Credit Card Payments will be charged a 2.90% service fee.


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