Jenzabar University

Contract Training Registration Form

Directions:

It is important that you use your personal email and home addresses to ensure that we can maintain communication with you in the future. Using your work email/mailing address may limit our ability to verify your participation in the course.

• - Enter your Student Information, click Next
• - Enter your Contact Information, click Next
• - Select your Employer and Course from the Dropdowns, click Next 
  
  •  
• - Click Submit

Student Information

First Name

Last Name

Suffix

Birth Date (MM/DD/YYYY format):

(Please be accurate - this information is used to create your initial password.)

SSN

Please select the gender with which you most identify:

Your race (select all that apply):

Ethnicity (check one):

Education (highest completed):

Release of my educational records:

Have you ever been convicted of a crime or adjudication other than a minor traffic offense?

If you answered yes to the above question, please explain the circumstances of your conviction(s).

Contact Information

Address Line 1

Address Line 2

City

State

Zip Code

Primary Phone Number

Email Address

Confirm Email Address

Employer and Course Information

Employer

Department

Course

Course Code

Course Title

Course Cost

Press the submit button below to submit your course registration.  We will contact you shortly.  If you have any questions please contact Workforce and Professional Development at (207) 755-5280.