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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
$450
(includes $100 registration fee)
Out-of-State Participants
$900
(includes $100 registration fee)
Students (NJ full-time status required)
$225
 (includes $100 registration fee)

Students (Out of state full-time status required)

$450
(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.

 
First Name
Last Name
Degrees/Certifications
Years counseling experience
Title
Organization
Address
Address (cont.)
City
State
Zip Code
County
Work Area Code+ Phone
Work Area Code + FAX
Email REQUIRED
How did you
hear about this training?
Home Information
Home Address
Home City
Home State
Home Zip Code
Home Area Code+ Phone

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