Please print legibly. Date: Name: Last First MI Former/Maiden (if applicable) Date of Birth / / M F Month Day Year Marital Status: Single Married Single Parent SECTION A CONTACT INFORMATION Mailing Address Street Apt. # City State Zip Code Home Telephone Number: Work Telephone Number: Email Address Home Tribal Agency (if applicable) Enrollment # SECTION B COURSE/TRAINING INFORMATION CEU Course/Training Title: SECTION C PAYMENT Indicate the method of payment you will use for the CEUs (PLEASE CHECK ONE): Street City/State/Zip Other Form of Payment: SECTION D SIGNATURE I have read the above application and answered all questions to the best of my knowledge. Any false information given will be cause for my disqualification for CEUs from UTTC. I agree to abide by the rules and regulations of . I authorize the Distance & Continuing Education Department to solicit information necessary for consideration of qualification for CEUs. Signature: SECTION E DIRECTIONS FOR COMPLETION Submit this application to the Continuing Education Department in one of three ways: Email to Mail to: United Tribes Technical College ATTN: Dr. Jen Janecek-Hartman 3315 University Dr. Bismarck, North Dakota 58504 Fax: Attn: Dr. Jen Janecek-Hartman at 701-224-7236
Please print legibly. Date: Name: Last First MI Former/Maiden (if applicable) Date of Birth / / M F Month Day Year Marital Status: Single Married Single Parent SECTION A CONTACT INFORMATION Mailing Address Street Apt. # City State Zip Code Home Telephone Number: Work Telephone Number: Email Address Home Tribal Agency (if applicable) Enrollment # SECTION B COURSE/TRAINING INFORMATION CEU Course/Training Title: SECTION C PAYMENT Indicate the method of payment you will use for the CEUs (PLEASE CHECK ONE): Street City/State/Zip Other Form of Payment: SECTION D SIGNATURE I have read the above application and answered all questions to the best of my knowledge. Any false information given will be cause for my disqualification for CEUs from UTTC. I agree to abide by the rules and regulations of . I authorize the Distance & Continuing Education Department to solicit information necessary for consideration of qualification for CEUs. Signature: SECTION E DIRECTIONS FOR COMPLETION Submit this application to the Continuing Education Department in one of three ways: Email to Mail to: United Tribes Technical College ATTN: Dr. Jen Janecek-Hartman 3315 University Dr. Bismarck, North Dakota 58504 Fax: Attn: Dr. Jen Janecek-Hartman at 701-224-7236
2015_ICEHAP-RegistrationApplication.docx