registration

Enriching Lives Through Technology

HOME | CONTACT | FAQ

registration

• application • courses • registration • scholarship • testimonials •

Course Registration Form for all TechWorks Partners using a Verizon scholarship grant

To register an individual for a course using a Verizon eTraining grant:

(NOTE: The organization must first be approved for the eTraining scholarship program. If the name of the Organization does not appear in the list below, please contact Salem CyberSpace or click here to complete and submit an application. )

Organization Name:

Applicant (select one): Staff Client

First Name Last Name

Applicant's Address:

Street:

City:

State:

Zip Code:

Phone: Email (if you do not have email, please put email of your organizational contact):

Applicant's Email Contact's Email

Course Selected:

Course Start Date:

Select Date

I confirm that the above information is correct. I understand that this is not an offer for financial assistance, but only an application. I certify that I am an employee of the organization named above, which is a 501c3 nonprofit organization