Registration Form



Registration Form

Please complete this form and then print and mail/fax to RTC

Students wishing to register for more than 9 credits in the fall or 12 credits in the Spring or Summer must first call 800-433-4740.

|Last, First, Middle Initial |      |Gender | |

|Birth date (mm/dd/yyyy) |      |Social Security #/Student ID |      |

|Address |      |

|City |      |State |      |Zip |      |

|Email |      |

|School Building |      |

|School District |      |

|Home Phone |      |Cell Phone |      |School Phone |      |

|Race/Ethnicity |Select one: |

| |Hispanic/Latino of any race Non-Hispanic/Latino |

| |Select all that apply: |

| |Hispanic/Latino of any race American Indian or Alaska Native |

| |Asian Black or African American |

| |Native Hawaiian or Other Pacific Islander |

| |White or Caucasian I choose not to disclose this information |

|How did you hear about us? | |

| |Please explain if you have select other or convention       |

Please list the class(es) you are registering for:

|Course & Section No. |Location (Town) |Beginning Date (mm/dd) |

|(ex. EDIN565-123) | | |

|      -       |      |      |

|      -       |      |      |

|      -       |      |      |

|      -       |      |      |

Method of payment:

Check or money order enclosed payable to “RTC for La Salle” or “RTC for TCNJ”

Check Amount: $      Check #:     

I hereby authorize the use of my Visa Mastercard Discover

Credit Card Number     

Expiration Date (mm/yy)     

Amount $     

Security Code     

(last 3 digits on back of card)

Please check here if you would like us to automatically charge the remaining balance for the class(es) listed above three business days before the start of each.

(Regional Training Center(486 Route 10 West, Randolph, NJ 07869(

(800-433-4740(fax 973-659-0700((

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