REGISTRATION FORM FOR BINGHAMTON UNIVERSITY
LEAN SIX SIGMA BLACK BELT Training
starting June 13, 2016
FIRST NAME: ____________________MI:___________LAST NAME:__________________________
TITLE/DEPT. ________________________________________________________________________
COMPANY/ORGANIZATION: ___________________________________________________________
ADDRESSS:__________________________________________________________________________
CITY, STATE, ZIP:______________________________________________________________________
PHONE:_____________________________________________________________________________
EMAIL:______________________________________________________________________________
GRADUATION YEAR (BU Students/Alumni ONLY):____________________________________________
FULFILLMENT OF GREENBELT PRE-REQUISITE :
☐BU Lean Six Sigma Green Belt May-June 2016
☐BU Lean Six Sigma Green Belt January 2016
☐BU Lean Six Sigma Green Belt May-June 2015, 2014 or 2013
☐BU Lean Six Sigma Green Belt January 2015, 2014 or 2013
☐BU/Dartmouth Lean Six Sigma Green Belt January 2012
☐Other (Please list the course, when taken, and where taken)
I would like to register for LEAN SIX SIGMA BLACK BELT:
(Early Registration thru 6/6/16. Registration ends 7/1/16.)
☐$1950 Industry
☐$1850 BU Alumni, Non-BU Student, Non-Profit, Government
☐$925 Current BU Student or December 2015-May 2016 Graduate
BU Student B # ____________________
☐$50 Late Fee (if registered between June 7, 2016 and July 1, 2016)
I am paying by:
☐CHECK (payable to Research Foundation 67070 )
☐CREDIT CARD
☐PO# ___________________.