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Level I, $395.00  
       Specify Program Location: Date:

Level II, $275.00

       Specify Program Location: Date:

Advanced Practice Seminars, $135/per seminar day or $395.00 for all three days

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       Please select number of days attending: 
      1 Day - Date:    2 Days - Dates:   3 Days - Dates:

Participant Information:

Name
Address (Street)
Mail Add (if different)
City, State, Zip
E-mail
Office Phone
Cell Phone
Home Phone
FAX (for registration confirmation)
Organization

Method of Payment:

Credit Card	Visa   MasterCard
Card Number:
Card Expiration:
Name on Card:
Mailing Address on Card: (include State & Zip)
Mailing a Check

Any Special Needs?

Any Questions or Comments?

* Payment is required at the time of enrollment.
* Cancellation requests received up to two weeks prior to the program date will be refunded at 75% of the registration fee or full credit at another site during the calendar year. 
NO REFUNDS WITHIN THE TWO WEEKS PRIOR TO PROGRAM DATE.