This will insert records into the
“Registration_development_site” table
Enrollment Form
* Username:
(
Note:
The username is the name you plan to use to login to CMH OLE. This CAN NOT be changed later.)
* Email Address:
(Note:
Please enter your name below EXACTLY as you would want it to appear on a certificate.)
* Last Name:
* First Name:
Mid. Initial:
* Address:
* City:
* State:
Arnor
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
MA
MD
ME
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
(if not from the Unites States, select "none")
* Zip:
+ 4
*Country
(if not Middle_Earth, type in country)
Is this a home address?
---
No
Yes
Phone:
Area
Code:
Number:
Ext.:
SunCom #:
(if applicable)
Fax#:
Area
Code:
Number:
Job Title
Employer Name:
Highest Degree:
First Profession:
License # 1:
Second Profession:
License # 2:
Identify the type of agency/organization/facility with which you are associated
(Check all that apply):
Consumer/family member
DCF ADM office
Advocacy group
Community agency
Other government agency
Community mental health center
Substance abuse facility
Professional association
Other mental health facility
State hospital
School/SEDNET
Other... (please specify below)
Other hospital
Higher education institution
To process your enrollment information, click the
Submit
button below.
IMPORTANT:
Clicking the submit button below DOES NOT create a password for you. You must also click the submit button on the following page (the
“Enrollment Information Verification
” form) before a password is generated and emailed to you.
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