Jenzabar University

Registration Form Instructions:

To successfully complete the registration process, fill-in all required questions on all sections of the form below.

There are 45 seats available for this program and we will fill the cohorts on a first-come, first-served basis.

Please don't forget to click the SUBMIT button at the end to complete the registration form. You'll get a follow-up e-mail from the Center for Workforce and Professional Development with additional information about your next steps!

If you have any questions, please call 207-755-5280 for answers!

Please detail your interest in a career in the software development field and any programming learning or self-study you have done.

Expand on the Windows computer system (with Internet and Administrative access to install programs) which you will use in the course.

How did you hear about this course?

Student Information

ID Number:

First Name:

Middle Name

Last Name

Suffix

Maiden / Other Birthname

Birth Date (MM/DD/YYYY format):

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

Social Security Number: (please include dashes) 

We respect your privacy. Access to your Social Security Number is restricted but is requested in order to evaluate program outcomes. 

Please select the gender with which you most identify:

Your race (select one or more):

Your Ethnicity (check box)

Education (highest completed):

Are you a Maine state resident? (If yes, documentation may need to be provided at a later date to validate residency.)

As a non-Maine resident, do you intend to work and/or live in the state of Maine at the completion of the training program?

Contact Information

Address:

Address Line 2:

City:

State:

Zip Code:

Home Phone:

Mobile Phone:

Email:

Employer: (Enter NONE if you are currently unemployed)

Do you currently have a paid position or is it volunteer work?

Salary or Hourly Income?

Please share your current rate of pay

I hereby grant CMCC permission to share my educational records, including registration, attendance, progress, and results, with the Maine Community College System for grant reporting purposes.

I also agree that as a participant of the grant funded program, I will provide validation of certification credentials, and updated information on employment and wage/salary changes as a result of the training/certification.