Indiana University Bloomington

Registration Form

Instructions: Fill out the fields and click the submit button to register online. You may also use our printer-friendly version to mail your registration form.

To register for a course offered by University of Wisconsin - Whitewater at Green Bay or Milwaukee, please use the registration link on "Course Descriptions" page for that particular course.

 

Student Information
First Name: (required)
Nick Name:
Last Name: (required)
Title:
Company:
Street Address: (required)
City: (required)
State: (required)
Zip: (required)
Home Phone: (required)
Work Phone: (required)
Cell Phone:
Email: (required)
I have an academic degree in safety and health: (check all that apply)
AS
BS
MS
I have a CHST Yes        No
I have an ASP Yes        No
I have a CSP Yes        No
Other Certifications:
I have                        years experience in construction safety.
I have                        years experience in general industry safety.
I have taken: (check all that apply)
OSHA 510
OSHA 511


Security Information

IMPORTANT!

For security reasons, what is the last letter of the alphabet in UPPER CASE?

Note: The answer to the above question is required or else the registration form will not be submitted correctly. The answer to this question is used to stop fake computer generated registrations.

Hint: The answer is a last letter in sequence "a,b,c,...." but in upper case.


Course Selection

You can register for up to three different courses at a time using the drop-down menus below:

Class #1

Class #2

Class #3