SUSSEX TECH ADULT CAREER CENTER – SPRING 2018

■ Registration Form ■

The Adult Career Center @ Sussex Tech ▪ 105 North Church Road, Sparta, NJ 07871 ▪ 973-383-6700 ext. 286 Fax 973-383-0337

 

Name_________________________________________________________SS#________________________________________________________

 

Address______________________________________________________ Daytime Phone _________________________________Ext.__________

 

Town, State, Zip_______________________________________________ Evening Phone________________________________________________

 

E-mail Address__________________________________________________________________ Date of Birth________/___________/___________

 

Select One:  Male□   Female□                                                                                                                 Are you a Registered Apprentice? Yes___ No___

 

Please register me for the following course(s):

Course No._________________ Course Name_________________________ Day(s)__________ Tuition (including all fees) $_______________

Course No._________________ Course Name_________________________ Day(s)__________ Tuition (including all fees) $_______________

Course No._________________ Course Name_________________________ Day(s)__________ Tuition (including all fees) $_______________

                                                                                                                                                                                         TOTAL* $_______________

 

Checks Payable to Sussex Tech  (*Includes $20 Registration Fee)

Please select payment method. Full payment must be made when registering by mail, fax or in-person.
Money Order or Check Number__________________ □Cash (In-Person Only) □Credit Card: □Visa □MasterCard

Card Number______________________________________________Expiration Date__________________________ CVV#_________

Name of Cardholder_______________________________________________Signature______________________________________

Statistical Information: In order to comply with state and federal requests for statistics, we ask that you please answer these questions. All information  you provide is strictly confidential in accordance with the Family Education Rights and Privacy Act of 1974. Thank you for your help.

Ethnic Background: □White, Non-Hispanic □Black, Non-Hispanic □Asian □Hispanic □American Indian/Alaskan Native □Native Hawaiian/Pacific Islander