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Open Enrollment Application

Note: All fields marked with * are required

Advance reservations are strongly encouraged. Reservations do not guarantee acceptance to the program but will assure priority in the admission review. We strive to admit a select group of qualified participants to our programs.

Advance reservations may be made by calling us from the U.S. at 800-311-6364 or from outside the U.S. at 814-865-3435.

Penn State encourages qualified persons with disabilities to participate in its programs and activities. If you anticipate needing any type of accommodation or have any questions about physical access provided, please contact us at 814-865-3435 in advance of your participation or visit.

Program Title:*
Program Dates
How did you hear about the above program?
If you attended a PSU Executive Program, please specify which one/when.
If direct mail, please specify VIP code located above address.
If other, please elaborate.

Contact Information

Prefix:
First Name: *
 MI
 Last Name: *
Nickname/Name you want on your tag: *
 Gender: *
Job Title:*
Company/Organization:*
Division:
Country:*
Business Address:*
City:*
 State:
 Zip:*
-
Business Address:
City:*
 Province:
 Code:*
Business Address:  (Please include city, state/province, postal code)
E-mail Address:*
Business Phone:*
Fax:
Date of Birth: (mm/dd/yyyy)

Company/Organization Information

Please choose if you or your company is a member of the following:
Describe your company including products, services and markets:
Parent Company Name (if applicable):
Parent Company Address (if applicable):
Number of personnel in total organization:
Number of personnel in activity you manage:
Number of people who report directly to you:
Sample titles of people who report directly to you (at least three):

1.

2.

3.

Summary of Current Major Responsibilities
Principal Management Positions Held (List in Chronological order)
(1) Name of Company:


Title:


From - To:
(2) Name of Company:


Title:


From - To:

Education
For your most recent degree:
College/University:
Major:
Degree Conferred:
Year of Graduation:
If this degree is not from Penn State, are you a PSU alum?

Company Sponsorship

In sponsoring the applicant, the corporation should recommend only those candidates with strong potential for both continued growth and contribution to the overall mission of the firm through knowledge-based development.

If this nominee is accepted for attendance, it is understood that he or she will be completely free of official duties while attending the program and will not be absent for business reasons from any regularly scheduled session.

Name of Nominating Officer: *
Title of Nominating Officer:*
Company/Organization:*
Business Address:* (Please include city, state/province, postal code)
Business Phone:*
E-mail Address:*

Management Development/HR Contact
Name:*
Title/Position:
Company/Organization:
Business Address:* (Please include city, state/province, postal code)
Phone:
E-mail Address:

Payment of Fees

Payment of fee is due and payable upon notice of the applicant's acceptance into the program. Fee invoice should be forwarded to:

Name:
Title/Position:
Company/Organization:
Country:
Business Address:
City:
 State:
 Zip:
-
Business Address:
City:
 Province:
 Code:
Business Address: (Please include city, state/province, postal code)
E-mail Address:
Business Phone:

Checks should be made payable to The Pennsylvania State University or payment may be made by credit card by calling 814-865-3435 with card details.

Full payment is expected prior to or on the program start date. We will accept check, cash, credit card, electronic transfer or a commitment to pay via purchase order. In the case of an emergency that prevents you from attending the program, please notify our office as soon as possible to discuss the cancellation or transfer of your registration per the policy listed below.

If your company uses purchase orders for educational services such as this, please present us with a purchase order number as soon as possible following your confirmation notice and no later than one week prior to the program start date.

Transfer, Withdrawal, Refund and Cancellation Policy

Transfer, Withdrawal and Refunds
If an accepted applicant finds it necessary to transfer to another session of the same program, one transfer will be allowed with no charge if arranged more than six (6) weeks prior. Additional transfers, transfers to another program, or those arranged less than six (6) weeks prior incur a charge of 10% of the current program fee.

The sponsoring company may identify a replacement, but the replacement candidate must be accepted for the program by meeting program requirements.

If an accepted applicant withdraws completely from a program, the following refunds will apply if Penn State Executive Programs is notified in writing within the time period stated:

  • A full refund will be given if notification is received more than six weeks prior to the start of the program.
  • A 50% refund will be given if notification is received between two (2) and six (6) weeks before the start of the program.
  • No refund will be made if notification is received two (2) weeks or less before the start of the program.

Note: All notification of withdrawals, transfers, and substitutions must be confirmed in writing by the registered participant or their agent. If written notification is not received, the full program fee will be assessed.

Cancellations:
The University may cancel or postpone any course or activity because of insufficient enrollment or other unforeseen circumstances. If a program is cancelled or postponed, the University will refund registration fees but cannot be held responsible for any other related charges or expenses, including cancellation/change charges by airlines or travel agencies. In the case of postponement, as an alternative to a refund, program fees may be transferred to another session of that program.

For any questions or additional information, please contact:

Penn State Executive Programs
Smeal College of Business
The Pennsylvania State University
382 Business Building
University Park, PA 16802-3603

Toll-free within U.S.: 800-311-6364
Outside U.S.: 814-865-3435
Fax: 814-865-3372
On the Web: http://www.smeal.psu.edu/psep/index.html
E-mail: psep@psu.edu