Tobacco Dependence Program
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TRAINING REGISTRATION
Please submit the online registration form below,
or print this form and fax it to (732) 235-8297.
To complete your registration, send a check
(made payable to UMDNJ-Tobacco Dependence Program), to:
Registration, UMDNJ-Tobacco Dependence Program
317 George Street, Suite 210, New Brunswick, NJ 08901
For more information send an email to info@tobaccoprogram.org
or call the Tobacco Dependence Program at 732-235-8222
The charge for this training is as follows:
Non-Refundable Deposit/Registration Fee $100
In-State Participants $500
(includes $100 registration fee)
Out-of-State Participants $975
(includes $100 registration fee)
Students (NJ full-time status required) $250
 (includes $100 registration fee)
Students (Out of state full-time status required) $500
(includes $100 registration fee)
Need-based scholarships available to those working in NJ facilities.
To be eligible for student rate, proof of current student status is required.
TRAINING CONFIRMATION
Upon submitting your registration, a separate confirmation will be sent to you.
If you do not receive this within 3 days,
please contact us at 732-235-8222.
Please choose the training dates you would like to attend
First Name Enter your first name
Last Name Enter your last name
Degrees/Certifications
Years counseling experience
Title
Organization Enter your organization name
Address Enter your address
Address 2
City Enter your City
State Enter your State
Zip Code Enter your Zip Code
County
Work Area Code+ Phone Enter your work phone
Work Area Code + FAX
Email Enter your email address
How did you hear about this training?
Home Information
Home Address
Home City
Home State
Home Zip Code
Home Area Code + Phone
The Tobacco Dependence Program at UMDNJ-School of Public Health is asked by many, including federal and local government agencies, grantors, and our own institution, to describe the racial/ethnic backgrounds of our training participants. In order to respond to these requests, we ask you to answer the following questions:
Do you consider yourself to be Hispanic/Latino? Yes No
In addition, select one or more of the following racial categories to describe yourself:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Other Specify
I do not wish to answer
Do you have a disability? Yes No

We appreciate your assistance in providing us with this information. Thank you.

Remember to send your payment to:
UMDNJ-Tobacco Dependence Program
317 George Street, Suite 210, New Brunswick, NJ 08901

If you are returned to our home page, rather than a confirmation page, your registration has not been recorded. If this happens, please call Amy Schmelzer at 732-235-8220 for assistance.
Otherwise, your registration has been received and you will hear from us shortly.