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The Division of Continuing Studies The Delta s Link to Lifelong Learning PARTICIPANT APPLICATION FOR CEU CREDIT In order to receive Continuing Education Credit for a program this form must be completed by each participant and submitted to the Division of Continuing Education with payment attached to the form. PLEASE NOTE Payment by money order preferred. There is a minimum three-week wait for transcripts/certificates from date check payments are deposited in Student Business Services. PROGRAM INFORMATION Program Title Sponsoring Organization Location Date s PERSONAL INFORMATION Please do not leave any questions blank Name Social Security Number Address City State Zip Daytime Phone Evening Phone E-mail Address No Late Applications will be accepted Sex circle one Date of Birth Legal Resident of Mississippi Marital Status circle one Religion please indicate Race/Ethnicity please circle one Mail a CEU Transcript circle one Male / Female Yes / No Single / Married / Separated / Divorced / Widow White non-Hispanic / Black non-Hispanic Hispanic of any race / Asian or Pacific Islander American Indian or Alaskan Native As an institution of higher education and in the spirit of its policies of equal employment opportunity Delta State University declares its policy of equal education opportunity. All applicants for admission will be considered without regard to applicant s race color religion sex national origin disability related to program performance disable veteran status or Vietnam era veteran status. The Division of Continuing Studies The Delta s Link to Lifelong Learning PARTICIPANT APPLICATION FOR CEU CREDIT In order to receive Continuing Education Credit for a program this form must be completed by each participant and submitted to the Division of Continuing Education with payment attached to the form* PLEASE NOTE Payment by money order preferred* There is a minimum three-week wait for transcripts/certificates from date check payments are deposited in Student Business Services. PROGRAM INFORMATION Program Title Sponsoring Organization Location Date s PERSONAL INFORMATION Please do not leave any questions blank Name Social Security Number Address City State Zip Daytime Phone Evening Phone E-mail Address No Late Applications will be accepted Sex circle one Date of Birth Legal Resident of Mississippi Marital Status circle one Religion please indicate Race/Ethnicity please circle one Mail a CEU Transcript circle one Male / Female Yes / No Single / Married / Separated / Divorced / Widow White non-Hispanic / Black non-Hispanic Hispanic of any race / Asian or Pacific Islander American Indian or Alaskan Native As an institution of higher education and in the spirit of its policies of equal employment opportunity Delta State University declares its policy of equal education opportunity. All applicants for admission will be considered without regard to applicant s race color religion sex national origin disability related to program performance disable veteran status or Vietnam era veteran status.

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