Applied and Industrial
Mathematics Institute for Secondary Teaching
July 14-17, 2014

Registration Form

Center for Industrial Mathematics and Statistics
Department of Mathematical Sciences
Worcester Polytechnic Institute
Worcester, MA 01609

Please fill in all requested information:

1. General Information

Family Name:
First Name:
Middle Initial:

2. School Information

School District

City, State, Zip

3. Education

List all degrees you have obtained.

Name of Institution Area of Study Degree Received

4. Credit

Do you want a PDP certificate?

5. Teaching Interest

Please describe your teaching activities and why you want to participate in the program:

6. Special Needs

If you are a disabled participant or if you have special needs, please let us know by filling in the following box.

7. Submit the Application

Type in the following two words.

For any questions, please contact:

Tel: 1-508-831-5241
Fax: 1-508-831-5824

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Last modified: Jun 20, 2010, 09:03 EDT
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