Instructional Dynamics for the Technical Trainer Registration Form

Personal Information

First Name

Middle Name or Initial

Last Name

Suffix

Email Address (Please use this email with future communications with us)

Cell Phone Number

Phone Number

What is your current level of education?

Employer/Organizational Name:

Are you currently a technical trainer?

YesNo

If yes, where?

Mailing Address

Street

Street 2

City

State

Zip or Postal Code

Signature

Please validate the below statement and provide your name and date for an electronic signature.

Upon receipt of your signature, you attest that all the information provided is true and complete to the best of your knowledge and that you understand that false information will jeopardize your admission to and continuation in these Averett Programs.

YesNo

Please type out your full legal name:

Please date your signature

*Averett University is committed to providing an inclusive and welcoming environment and to the principle of equal opportunity in education and employment. Averett prohibits discrimination against and harassment of any student, employee, applicant for admission or for employment, third party or community member because of race; color; national or ethnic origin; age; religion; disability; sex; sexual orientation; gender; gender identity and expression; genetics; veteran status; retaliation; and other characteristic protected under applicable federal or state law.

Contact Information