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PROFESSIONAL MEDICAL EDUCATION ASSOCIATION, INC.
USE THIS PAGE TO ELECTRONICALLY REGISTER FOR COURSES.
Checks are made to Professional Medical Education Assn, and mailed to 4243 Diplomacy Drive, Columbus, OH 43228
You may also Print Out and Complete this form, then mail to the address above or fax to 305-946-0232

Electronic Registration form - all courses.

REFUND POLICY   - Please read this policy prior to registration. Laser Repair and some other small classes are noncancellable and nonrefundable.                                            
"*" Indicates required information
*Name
 -- as you would like it to appear on the Certificate
Title/Dept.
Company / Hospital
 *Work Address Preferred
Home address OK

 

Home or Work address and phone?

Employer Paid?    If this is an employer paid registration, original or reissue of certificates will be mailed only to the address above, so list your employer work address.

Is this employer paid?  YES            NO
*Registrants E-mail
Confirmation will be sent via email, in addition to any course updates.


*Phone
*Course Name



 



Choose the Correct Course
PLUS - type in the course date & city below:
 

NCLE Laser Certification  :

visit www.LaserCertification.org for more information on this   

Do you tentatively plan on taking one of the NCLE Laser Certification Exams at the end of this course (if offered)?
Yes                  No

If Yes, which type of exam will you be taking?
call us if you want to take more than one exam.
*Type-in Course Date & City:
Add a copy of the 2005 ANSI 136.3 Standards ? Yes, include the ANSI 136.3 for $155, plus $15 for shipping

*Payment Method:

*Enter either Purchase Order # or Credit Card Info
Purchase Order: #
Credit Card:

(Visa, MC, AX, Discover)

Cardholder: :
Card Number:
Expiration Date:      

     You should receive an e-mail confirmation of your registration.  Call us at 800-435-3131 if you don't.

"*" - Denotes Required Information 

*Note - The amount charged to your credit card will be the discounted price of the course fee (when applicable) as listed on the course information pages. The amount invoiced on a purchase order will be the full course amount, with a note indicating that the discount may be taken if payment is received by us prior to the course date.