Police Officers' Association of Nebraska
A contributing member of the Law Enforcement Community since 1953.
REGISTRATION FORM FOR POLEX
Dana College , Blair , NE
June 6 - 17, 2005
________________________________________________________ Social Sec#__________________
Last name, First Name, Middle Initial
Title________________________ Company or Organization______________________________________
Business address (no. and street or box no.)
City, State, ZIP code
Business phone__________________________Business fax______________________________________
Are you a Penn State alumna/us?
Method of Payment Cost $985 per person
Lodging option (choose)
___without weekend $200
___with weekend $280
Meal option ___ $214.40 (excludes weekend)
Your payment, in full, must accompany your registration form. Fax or telephone registrations must be accompanied by credit card payment information.
_____ Enclosed is a check for the amount indicated, payable to Penn State .
_____ Enclosed is a purchase order (made payable to Penn State ) or letter of authorization from employer
or organization. ( IMPORTANT: For this payment option the signature of Budget Officer or Chief of Police
is required below).
Budget Officer/Chief's Name (please print/signature also required)
Charge the fee(s) I have checked to my: MasterCard Visa American Express Discover
Cardholder's name (please print)
____________________________________ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __/__ __
Cardholder's signature Charge no. Exp. date (mo/yr)
(Credit card charges cannot be processed without signature and expiration date)
BEFORE MAILING SEND TO Penn State Justice and Safety Institute
1. Complete all information The Pennsylvania State University
2. Sign check and make payable to Penn State 305 Lubert Building, Innovation Park
3. Enter complete credit card information, including expiration date University Park , PA 16802-5202
(Complete information and payment are necessary for registration.) Fax 814 863-3108
The Social Security Number (SSN) you provide for enrollment purposes, or when requesting specific services, will be used by the University to verify your identity for official record keeping and reporting. If you choose not to supply your SSN, certain services, such as transcripts, enrollment verification, tax reporting, financial aid, and other services may not be available to you, and Penn State cannot guarantee a complete academic record for you. Your SSN will be stored in a central system and only used for official reporting and record keeping. It will not be used as a primary source to identify you within the Penn State system; the PSU ID will be used as the primary identifier.