In compliance with Act 48, the University of Pittsburgh at Titusville will report college credits earned at UPT to the Pennsylvania Department of Education and the student’s employer (see below) for the purpose of tracking professional development.

For accurate reporting of your earned credits, COMPLETE THE ENTIRE FORM, as soon as possible, and return it to Office of the Registrar, Davis Hall, University of Pittsburgh at Titusville, P. O. Box 287, Titusville, PA 16354.

Name ___________________________________________________ Telephone ____________________

Address ____________________________________________ E-mail __________________________

___________________________________________________________________________________

By signing this form I give permission to the University of Pittsburgh at Titusville to release any academic records to the Pennsylvania Department of Education to fulfill Act 48 requirements.

Are you presently employed?   Yes   No          Do you wish your employer notified of the completion of the course(s) listed above?   Yes   No

Date of completion of course/workshop _________________________________________________

Grade or hours received ______________________________________________________________

Authorizing signature ________________________________________________________________