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TIAC Course Registration Form
(Do Not Use For Workshop Registration)

All information requested is required to process your registration request and is held confidential. Forms submitted with incomplete information cannot be processed. If you prefer to download a copy of the TIAC Course Registration Form to be mailed to us, please click here.

TO MOVE THROUGH THE FORM USE YOUR [TAB] KEY
Pressing the [ENTER] key before completing the form will
cause an error and your form will not be sent.

Today's Date:    Course Start Date:

Course Name:

Full Legal Name (For Certificate):

Social Security Number:     Date of Birth (xx-xx-xx):

Home Address (Number/Street):

City:     State:     Zip Code:

Phone:    Email:

Employers Name:

Occupation:    How long?:

Work Address (Number/Street):

City:     State:     Zip Code:

Phone:    Hours:

Can you receive calls at work?:    Best time to call:

IN CASE OF A MEDICAL EMERGENCY, WHOM SHOULD WE CONTACT?

Name:

Phone:    Relationship:

Sobriety Date (If Applicable):

Highest Level of Education Completed:

General guidelines suggest that Certified Counselors in sobriety have one (1) year in recovery.
While it is NOT a requirement for enrollment at TIAC, it may be a requirement for a job.

Please tell us how you heard about TIAC and why you want to take this course: