Registration Form

Instructions: You can fill out this form on the computer and print it by clicking the "Print Form" button at the bottom.

To register for a course offered by University of Wisconsin - Whitewater at Green Bay or Milwaukee, please use the registration link on "Course Descriptions" page for that particular course.

Mail the printed form with your check or copy of your purchase order to:

Heartland Center
400 E 7th Street, Poplars Room 629
Bloomington, IN 47405

Personal Information
First Name:
Last Name:
Title:
Company:
Street Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Cell Phone:
Email:
I have an OSHA 30-hour card in: (check all that apply)
General Industry
Construction
I have an academic degree in safety and health: (check all that apply)
AS
BS
MS
I have a CHST Yes        No
I have an ASP Yes        No
I have a CSP Yes        No
Other Certifications:
I have years experience in construction safety.
I have years experience in general industry safety.
I have taken: (check all that apply)
OSHA 510
OSHA 511

Class Information

You can register for up to three different classes at a time using the drop-down menus below:

Class #1

Class #2

Class #3


Payment Information
Payment Type:
Amount: $
Check Number:
(Make check payable to Indiana University and mail to 400 E 7th Street, Poplars Room 629, Bloomington, IN 47405)
Purchase Order Number:
(Fax a copy of the PO at the time of registration to 812-855-7092 or attach to application form and mail to 400 E 7th Street, Poplars Room 629, Bloomington, IN 47405)