NAME
Name*
First Last
DATE OF BIRTH
Date of Birth*
SOCIAL SECURITY NUMBER
Social Security Number*
MAILING ADDRESS
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
CLASS IN WHICH YOU WISH TO ENROLL
Class*
Start Date*
Start Time*
CAMPUS
Campus*
- Springdale
- Ft. Smith
PREVIOUS PETRA ATTENDANCE
Have you previously been a student at Petra?*
- Yes
- No
PAYMENT METHOD
Only a Registration Fee of $50 will be charged to your card. You will need to pay for the course before class starts. Contact the office if you wish to utilize the tuition payment plan.
Payment Method*
- Visa
- Master Card
- CNA Class - No Pre-registration Fee Required
Name on Card
Credit Card Number
Expiration Date
Security Code (3 digit on back of card)
VERIFICATION
Terms of Service agreement*
- I have read and agree to the Terms of Service
Re-Captcha

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NAME