
Email:*
First:*	MI: Last:*
Social Security # (xxx-xx-xxxx):		Address:

Phone:
Work Phone:		City:
Cell Phone:		State:
Fax Phone:		Zip Code:
		Country:

You must obtain a required Professional Personnel ID# for us to submit requests for Act 48 Professional Development. You may establish this account through the PDE website - www.pde.state.pa.us//. Please make sure you use Microsoft Internet Explorer as your browser.

Professional Personnel ID#:*

Teaching Certificate Level:*		Activity Type:*
School District:*		Activity Title:*
Act 48 Contact Person: (at school district)*		Beg Date:*
Mailing Address:		End Date:*
(school district)*		Requested Credits/Hours:*

Electronic Signature:*	By checking this box, I hereby make my electronic signature. I have read and agree to all of the conditions of the electronic signature.



Notes/Comments:
Conditions of electronic signature:	To the best of my knowledge, all of the information submitted via this form is correct and complete. I am not attempting to gain access to, or modify, another person's account or personal information without their expressed permission. Any misrepresentation may be deemed just cause for any of the following: Collegiate Judicial Hearing Dismissal from the University Legal prosecution

*	Denotes a required field.

For More Information,
Contact:

lyles@rmu.edu
412-397-6237 phone
Massey Hall 2nd
More Info →