Health Services Education registration form for CHSER

The Center for Health Services Education
and Research
PO Box 1654, San Marcos, TX 78667-1654

Ph.512.392.4092 * Fax.512.392.1258
Email

Sponsor Signup

Fax to 512.392.1258 and if paying by check, mail payment or include credit card information.
Print this form and mail either with credit card information on the form or check payment:

Dr. Marian Upchurch
CHSER
PO Box 1654
San Marcos, TX 78667-1654

Company Information:

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

Method of Payment (please check choice):

Visa MasterCard Discover	Mailing a Check
Card Number: ________________________Expires:_________
Name on Card: __________________________
Card Billing Add (include State & Zip) ________________________State: __ Zip: ________