The University of Texas of the Permian Basin

ADVANCED PLACEMENT SUMMER INSTITUTE

JUNE 17-20, 2013

Registration Information

Please print/type all information clearly, one registrant per form. For additional registration, please
photocopy this form and have each registrant fill out a separate form. Be sure to retain a copy for your
records


(* Required)  
Title * Mr.
  Ms.
  Mrs.
  Dr.
First Name
Last Name
Billing Address
Billing City
Billing State
Billing Zip
School Name
School Address
School City
School State
School Zip
School Telephone
School Fax
Home Telephone
E-mail Address *
Please check ONE AP Session or Pre-AP Session for which you want to register. Please note that you can * AP English Language and Composition
  AP English Literature and Composition
  AP Spanish Language
  AP World History
  AP World Geography
  Pre-AP Professional Development in Mathematics HS
  Pre-AP Professional Development in Mathematics JH
Payment Information
The cost for the institute is $595.
Payment Method: * Purchase Order (give PO# below)
  Check made payable to UTPB (Participants' names must be listed on all checks)
PO#
 

Send this completed form and payment to the Continuing Education/Outreach Department, UTPB, 4901
E. University Blvd., Odessa, Texas 79762. No registrations will be received over the phone. All
registrants will receive a written confirmation notice. Register early. Seating is limited.

REGISTRATION DEADLINE: FRIDAY, MAY 17th, 2013