Thomas Edison State University


This form is to be used to register for professional certificate programs offered through the School of Applied Science and Technology.

General Information

First Name:*  MI:
Last Name:*  Date of Birth:
Street Address:*
Zip Code:*
Telephone:* Day Evening
Fax Number (if available):
E-mail Address:*
Highest Degree Earned:
Current Employer:
University ID#:
How did you hear about this program?
University website
colleague or friend newspaper other:
Web search advertisement brochure

Certificate Registration

Select the certificate(s) for which you wish to register below.

  • Professional certificates do not contribute towards earning a degree.
  • Payment for professional certificate programs is nonrefundable.
  • Registrations received without complete information or total payment will not be processed.

Radiation Safety Officer

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Course Code Title Cost
Total Cost:  


Have you ever been a Thomas Edison State University student? Yes No

* I have read the course description and completed the online course demonstration (if available) for the certificate program I am registering for.

Federal, State & Institutional Reporting Data

As an Affirmative Action/Equal Opportunity Employment institution, Thomas Edison State University prohibits discrimination in its policies, practices and procedures. For federal and state compliance purposes, the University is required to submit statistical data on the composition of its student body in an aggregate manner. This information is collected for reporting purposes only; it is not used in admissions decisions.

Female Male  
Please indicate if you are: (select one)
Hispanic or Latino Not Hispanic or Latino  
Please specify your race/ethnicity from the following categories: (select one or more)
American Indian or Alaska Native Asian Black or African-American
Native Hawaiian or other Pacific Islander White  

PLEASE READ and agree to the following terms and conditions:*

Credit and debit card payments are handled through a third party payment processor. A non-refundable convenience fee of 2.95 percent (with a minimum charge of $3.00) will be added to your total charges for this processor. The University does not receive any portion of convenience fee payments.

To avoid convenience fees you can pay via electronic check/ACH payment. Electronic payments require your bank routing and account numbers. The routing number and checking account number can be found on the bottom of your personal check.

I have read and agree to the above terms and conditions.

Method of Payment:*

Credit/Debit Card Electronic Check (ACH)

When paying by credit card or electronic check, you will be prompted for credit card/check information upon submitting this form.

Please note that payment must be confirmed for registration transaction to be completed.


I hereby certify that the above statements are true and correct to the best of my knowledge. I authorize the release of completion information on the above certificate program(s) to my employer, if my employer is paying for the certificate(s). I verify that I understand and agree to abide by the complete policy on academic integrity and procedures for academic discipline of academic integrity violations as stated in the Thomas Edison State University Catalog. I understand and accept that professional certificates do not contribute towards earning a Thomas Edison State University degree and, therefore, are not credit bearing, and that payment for professional certificates is nonrefundable.

* Required fields