Home Campus Directory | A-Z Index

PENN STATE FAYETTE, THE EBERLY CAMPUS
MAIL-IN REGISTRATION FORM
Registrar's Office
2201 University Drive
Lemont Furnace, PA 15456
Phone: 724-430-4144

Penn State students can schedule via the web using eLion. Others must complete this form and return it to the Registrar's Office.

Please print in ink or type. This form may be duplicated.

Last Name:_________________________ First Name:_________________________ Middle Name:_____________________
Social Security Number or PSU ID Number:_________________________________

Home Address
Street:______________________________ City:_________________________ State:______ Zip:__________

Home Telephone:______________________ Business Telephone___________________________

Ethnic Background Optional (check one)
_____ American Indian
_____ Alaskan Native
_____ Black/African American
_____ Asian American
_____ Hispanic American
_____ White American

Have you ever been enrolled at Penn State? _____ yes _____ no

Are you currently attending any other college or university? _____ yes _____ no
If, yes where? ______________________

Are you currently in academic drop status from Penn State or any other college or university attended? _____ yes _____ no

Please Schedule me for the following course (s):

Course Schedule Number      Number of Credits      Course Description                                  Section Number

_____________________     _______________      _____________________________      ______________

_____________________     _______________      _____________________________      ______________

_____________________     _______________      _____________________________      ______________

_____________________     _______________      _____________________________      ______________

_____________________     _______________      _____________________________      ______________

 

Signature:_______________________________________________________________ Date:____________