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State-Funded Registration Form
Student Information
First Name
Middle Initial
Last Name
Suffix
Maiden / Other Birthname
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:
Contact Information
Address Line 1
Address Line 2
City
State
Zip Code
Primary Phone Number
Email Address
Confirm Email Address
Course Information
Please enter the name of the short-term course you are interested in taking.
Course:
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) 755-5282.