TEACHING PERFORMANCE CENTER

KEAN UNIVERSITY

SCHOOL OF EDUCATION

WILLIS 110/UNION, NJ 07083

Telephone (908) 527-2042/Fax (908) 629-7068

 

Out-of-State Student Payment Form

(Incoming Student)

 

This form to be completed and submitted together with payment of fees in the form of a check or money order made payable to Kean University.  Grade(s) for the professional internship for an outgoing Kean student will be withheld until payment is received.

 

Date____________________                                     S.S.# ___________________________

 

Name of Student_____________________________________________________________

 

Street Address_______________________________________________________________

 

City______________________________ State_________ Zip Code___________________

 

Phone (Home)___________________ (Work)_______________ (Cell) ________________                           

Email Address________________________________________________________________

 

Visiting College Information

Name of College/University______________________________________________________

 

Street Address_________________________________________________________________

 

City_______________________________ State____________ Zip Code__________________

 

Contact Person______________________________  Phone # ___________________________

 

Email Address of Contact Person___________________________________________________

 

Fees to be paid to Kean University:

1.         Supervisory Fee                                $  950.00

2.         Cooperating Teacher Honorarium         100.00

3.         Supervisory Travel                                100.00

4.         Field Experience Fee                        $1,000.00

Total                                               $2,150.00

 

Return one copy of this form along with payment to:

 

Martha M. Mobley, Ph.D., Director

Teaching Performance Center

Kean University

1000 Morris Avenue

Union NJ 07083