CLEARFIELD COUNTY CAREER

     AND TECHNOLOGY CENTER

                          ADULT EDUCATION

       FAX:        814-765-5474

       PHONE:  814-765-5308

                                     1620 River Road

                                     Clearfield, PA  16830

      Please print and use this faxable form to register for class or to request

            information or a brochure about a specific course or program. 

      Do not send cash in the mail!   Please enclose check or money order.

      Visa and MasterCard are accepted

NAME __________________________________  PHONE _________________

ADDRESS                                                                      

          ________________________________________

          ________________________________________

          State__________ Zip__________ Email  __________________________

Course Name__________________________________         Cost____________

Course Name__________________________________         Cost____________

Course Name__________________________________         Cost____________

Amount Enclosed____________     

I Will Send Check by Mail  (Please Check)         ___________

I will call with my Visa or MasterCard information  (Please Check)    ___________

SEND INFORMATION ONLY (Please Check)   ___________

Comments or Questions:

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