Record of Non-Credit Course Enrollment Form

Please print and return the completed form to:

Penn State Outreach Non-Credit Registration Office
P.O. Box 410
State College, PA 16804

Fax: 814-863-2765

Please print and return the completed form to:
Penn State Outreach Non-Credit Registration Office
P.O. Box 410
State College, PA 16804
Fax: 814-863-2765

Identification

Student Name

Please enter your name.

PSU ID 9-digit Penn State ID number

Please enter your PSU ID.

*SSN *Only enter your SSN if you do not provide your PSU ID number.

Day Phone Number Please include area code

Please enter your daytime phone number.

Please enter a valid email address.

The following information is included in a record of non-credit course enrollment:

Name
PSU ID Number
Date of birth (month and day)
List of all non-credit course(s) taken at Penn State and grades if applicable

Record of Non-Credit Course Enrollment

Number of Copies

Please enter the number of copies needed

Penn State Campus(es) at which courses were taken:

Please enter the campuses in which courses were taken.

Address Where Record of Non-Credit Course Enrollment is to Be Mailed

Name

Please enter your name.

Street Address 1

Please enter street address.

Street Address 2

City

Please enter city.

State

Zip Code

Please enter zip code.

Authorization

I authorize Penn State to release my record of non-credit course enrollment to the above named party for purposes of:

Please enter release justification.

Please review your entries on this form. If all information is entered correctly, please print, sign, and submit the form to the address at the top.

Student Signature

Student Signature: _________________________________________________

Date: ____________________________

Student Signature: _______________________________________ Date: __________________________

Last Revised: 7/6/11