PSTA Registration Form

Please complete the Registration Form below to register for a Public Safety Training Course.

For questions, contact John Dixon, PSTA Operations Administrator
jdixon@sussex.edu or call 973-948-7897

Name & Course Number you are registering for? *

Attendee Information

FIRST NAME *

LAST NAME *

Last 4 digits of your Social Security # *

NJDFS ID # (if known)

DATE OF BIRTH *

Check this box if you are 16 or 17 years old

STREET *

CITY, STATE, ZIP *

PHONE NUMBER *

EMAIL ADDRESS *

GENDER *

Female
Male
Other

Fire/EMS/Police Department Information

Name of Organization

Organization Address

Chief of Department Information

Chief Name

Chief Phone

Chief Email

Chief Rank

Training Officer Information

Training Officer Name

Training Officer Phone

Training Officer Email

Training Officer Rank