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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 VideoConference Surgical Lasers

REFUND POLICY - Please read this policy prior to registration.

When you've completed your registration you'll be contacted with more information and assistance on how to join our Teleconference.
Payment is required in advance prior to receiving authorization codes to join the meeting.
You must have a computer with a high speed internet connection, digital projection and speakerphone or equivalent.
If you wish us to supply the Certificates & Credits you'll need to send us your sign-in sheet and printed list after the meeting.

Name of Facility
Facility Address This is where Certificates will go	Dept: # &Street City: State: Zip:
Primary Contact Person Info:	Name: Tel: Email:
Date of VideoConference: See Schedules Page for Dates	Type in Date:
Do you want us to issue the Certificates & Credits for the additional $20 per person?	YES NO - We'll issue our own
Payment Method $750 Fee	Please Enter either a P.O. or Credit Card Information Below. Payment must be received prior to shipping materials.
Purchase Order #
Credit Card Type:
Cardholder:
Credit Card Number:
Expiration Date:
Verification Code:	(Last 3 Digits of Security # on back of Card)

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