Registration Form | Professional Development Units Please Note: A separate registration form is required for EACH Course Number. All fields are required Credit Card # (VISA / Mastercard / Discover / Amex) Expiration Date 010203040506070809101112 20202021202220232024202520262027202820292030 Amount to charge Highest Degree Earned Degree Earned From Previously enrolled in Professional Development from UOP?YesNo Previously enrolled in a Courses4Teachers course YesNo Previously enrolled in a University of the Pacific course (aside from Courses4Teachers) YesNo School District (No Abbreviation) Office of Education or Induction program where you completed your Induction training Year of Program 12ECOMentor Academic Year of Program Course Number (Only one course number may be added) Course Title Number of Semester Units of credit Proof of Completion (if required) File types allowed: PDF,JPG, PNG, BMP, XLS, XLSX | Max upload: 2 MB S.S.# (Last four only) Phone (Home) Phone (Work) Birth Date * (Month) Select010203040506070809101112 (Day) Select01020304050607080910111213141516171819202122232425262728293031 (Year) Select195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009 First Name Middle Initial Last Name Address City State SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Your Email Additional Emails (All comma separated emails where you wish to receive information) Fee per unit : $50.00 Tuition Submitted Notes