Nicolet College Food Manager Continuing Education Registration Form
PLEASE PRINT.
First Name MI Last Name Social Security # or Nicolet Student ID #
Home Mailing Address City State Zip
/
/
Phone: Home
County of Residence Municipality of Residence Date of Birth
(Township/Village/City)
Gender: Male Female Email Address
THE FOLLOWING INFORMATION IS FOR STATE REPORTING PURPOSES. INFORMATION PROVIDED WILL NOT INFLUENCE COURSE ADMISSION.
Ethnicity: Are you Hispanic or Latino (regardless of race)? Yes No
Race: (Check all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White
Highest Educational Grade/Level Completed: 9 10 11 12 (includes GED/HSED) 13 14 15 16 (Bachelor’s Degree) 16+
What is the highest level of credential you have earned? No Credential GED HSED HS Diploma
Short Term Diploma 1 Year Diploma
2 Year Diploma Associate Degree Associate Degree + Additional Credential
Please check which class you prefer and include class date. Class Date Class No. Day Time Location Fee/Sr. Fee*
Food Manager Sanitation FULL DAY
62+ 30.27
4 pm - 6 pm
Please check if materials are needed.
Materials will be mailed to the address above upon registration.
BOOK Servsafe 7th ed. includes scantron
SCANTRON test answer Sheet ONLY
FEES ARE DUE WITH REGISTRATION *Senior Fees for person age 62+ are available for Continuing Education classes only
Office Use Only
Phone: Cell Work
PAYMENT INFORMATION: _____ Check/Money Order (payable to Nicolet College) _____ Credit card
_____ Mastercard _____ Visa _____ Discover
___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ Card Number
___ /___ Expiration Date ___ ___ ___ Verification Code (on back on signature panel)
__________________________________________ Card Holder Name/Signature
For more information: 715-365-4544 or email ce@nicoletcollege.edu
Mail or Email completed forms to:
jfox@nicoletcollege.edu
N
icolet College
Ce Registration
PO Box 518
Rhinelander, WI 54501
