Police Officers' Association of Nebraska
A contributing member of the Law Enforcement Community since 1953.

Police Officers' Association of Nebraska

Registration Form for POLEX

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)

Total$_________

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.