|
2010 Spring Seminar
South - Registration Form Location:
Kaiser Permanente Regional Laboratory |
||
|
Name: |
Check
the Workshop Course Numbers |
|
|
CLS/MLT License /
CPT Cert. #: |
|
|
|
Address: |
Saturday Morning ( [
] 102-100 (3.0 CE) |
|
|
City: State: Zip: |
||
|
Daytime
Phone: Email: |
||
|
Employer: |
||
|
Work Address: |
||
|
City:
State: Zip: |
Saturday Afternoon ( [
] 102-200 (3.0 CE) |
|
|
Work Phone: |
||
|
CAMLT Member?
[ ] Yes [ ]
No |
||
|
Member # /
Chapter: |
||
|
If member, do you
have 20/20 Option? [ ] Yes [
] No |
||
|
ATTENTION STUDENTS: Your program coordinator / school counselor
must sign/provide email/telephone contact here for acceptance: (Email / telephone) (Signature
of program coordinator/school counselor) (Accredited program/school) |
Method of Payment: Credit card,
check, or money order [ ] VISA [ ] MasterCard Expiration date:
________ Card #: __________ - ___________ - ___________ -
___________ Signature
(required for credit card processing): Make check payable and mail to: CAMLT FAX: 510.792.3045 Questions? Contact CAMLT Executive Office: 510.792.4441 Returned checks subject to a $20 fee Pre-Registration
Deadline: |
|
|
FEE Schedule: Course fees are
based upon a base registration fee of $5.00, plus a fee based upon the number
of continuing education units. Registration Fee: $5.00 ______ CE x $ _____ per CE
= _____ Members:
$15 per CE Non-Members:
$25 per CE Student
member: Free Sub-Total: $ _______ Less 10% Group
Discount: $ _______ Less 20/20 Option
Discount: $ _______ Total Due: $ _______ |
||