Basic
Information		      Professional Personnel ID:       


(If you do not know your Professional Personnel ID, please look it up on the Pennsylvania Department of Education website)
     KU Student ID:       
     Last Name:       
     Maiden Name:       

Maiden Name or Last Name on File with Kutztown University. If not applicable please enter "N/A" or "none".

     First Name:       
     Middle Initial:       
Address      Street:       
     City:       
     State       
     Zip Code:     

Contact
Information		      Home Phone       
     Work Phone:       
     Email:       
Teaching
Information		      School:     
     School District:     
     Certificate     

(If other, please enter the type)

Provide information below for the Credit Bearing Course

SUBMIT FORM ONLY AFTER THE COURSE IS COMPLETE.
Forms submitted in advance will not be processed.

Credit
Bearing
Course		      Course:     
Prefix (ACC, BUS etc):
Number:
     Course Title     

Please input full title, do not abbreviate
     Semester     
     Year     
Workshop/
Seminar:		      Workshop Name:     

Please input full title, do not abbreviate
     Date Started     
     Date Ended     
     Instructor     
     Semester     
     Year     
     Clock Hours Earned     
Please list topics you would like to see covered in future ACT 48 courses: