APPLICATION FORM

Application Form for Housing Authority Classes

In order to enroll in a course, the student must satisfactorily complete the prerequisite course or obtain the necessary permission.

If home or business address has changed since your last registration, circle YES

If title has changed since last registration, circle YES

Please list the course title of the course you'd like to register for: _______________________________
Please list the course number: ____________________________
What is the location? __________________________________

CHECK OR VOUCHER INFORMATION MUST ACCOMPANY REGISTRATION
Make check or voucher payable to Rutgers, The State University

Total amount: $___________
Method of payment: Circle one: CHECK VOUCHER

Name __________________________________________

Title __________________________________________

Social Security No. ________________________________

Home Address___________________________________

______________________________________________

Home Phone ____________________________________

Business Phone _________________________________

FAX _________________________________________

Agency: ______________________________________

Business Address _______________________________

_____________________________________________

Mail to:
State PHA Program
Center for Government Services
Rutgers, The State University
33 Livingston Avenue, Suite 200
New Brunswick, NJ 08901-1979