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: (if not from the Unites States, select "none")
* Zip: + 4
*Country   (if not Middle_Earth, type in country)
Is this a home address?  
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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