1766-2016 Rutgers 250
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One Stop Registration

Registration Form for Publicly-Funded* Registrants

*The purpose of this form is to formalize your request to register in one or more of our approved, continuing-education certificate programs; this form is for use by individuals who are applying for a Workforce Grant (or similar funding) through their local One-Stop Career Center, DVR or Trade Act Representative.

Questions? Please call us, 9:00 AM – 4:00 PM Eastern Time, Monday – Friday: (856) 225-2860 / or inquire via email. You may also check our FAQs page.

Please complete all fields:

Prefix (*)

First Name (*)

Last Name (*)

Home Address (*)

Home Address Line 2

City (*)

State/Province (*)

Specify "Other" State

Zip/Postal Code (*)

Phone (*)

Cell Phone

Other Phone

The following question is for Lean & Six Sigma Green/Black Belt classroom/online program only and is required as classroom portion takes place on premises of US Government defense contractor

Citizenship

Email Address (*)

Re-Enter Email Address (*)

Question or Comments (Please be Specific)

Subject to Approval of My Workforce Grant, I wish to take the following program

My Selection

Other (Please name the course.)

Important - please complete the following information:

One-Stop Career Center (City/Town)

Counselor Name

Counselor's E-Mail

Counselor's Phone

Counselor's Fax

Affirmation: By clicking the "Submit Registration" Button below, I affirm that I have read, understand and agree to comply with the Program Policies and Procedures found here.

Furthermore, I understand and agree that notwithstanding the Online Access Timeframes contained in the Policy, I will comply with the schedule for completion of my online and other coursework as specified in my Letter of Acceptance, if more restrictive.

It is the policy of the Rutgers the State University of New Jersey not to discriminate on the basis of sex, age, handicap, race, color, national and ethnic origin or sexual orientation in its education programs, admissions policies, employment policies, financial aid programs and other school administered programs. © 2009 Rutgers the State University of New Jersey.