SeminarRegistration

Phone

Must include Area Code & Phone # for US numbers.

Use format of 5554441212 - no spaces, hyphens or dots

SEMINAR:

Choose the Correct Course.If prepaid discounts, "early bird" registration, and/or group discounts are provided, that will be reflected on your invoice or actual credit card charge. PLUS - type in the course date & city below for clarification:

Name

It should be entered EXACTLY as it should appear on the Certificate

Facility Course Date & City Remarks? or Requests?

PAYMENT METHOD: Enter either a Purchase Order # or Credit Card Information

Purchase Order #

Payment is due prior to the start of the course, and by submission of this registration I agree to all payment terms of Professional Medical Education Assn which supercede any terms listed in our purchase order.

CREDIT CARD TYPE Cardholder Name Card Number: Exp Date

mm/yy

Security Code 3 or 4 Digit

If I am paying by credit card, I hereby authorize charges to my card for the item(s) ordered

By placing this order and clicking the SUBMIT button below, you acknowledge that you have read the REFUND POLICY and agree with its terms.

Privacy Policy

After you SUBMIT your order we'll followup within 1 business day after we've processed your registration.
All registrations are manually processed by staff so your card is not automatically charged.

Please type the txt into the box. Then SUBMIT.

Address Registrant Email Confirm Email

Electronic Registration form - all Seminars (or just the ANSI Standards alone)
(use the separate form for Online Training)

Once you have registered you will receive an email confirmation within about 1 business day.

NOTE: If you prefer to download a PDF Registration form and send back to us. CLICK HERE.
We understand that this form doesn't load correctly in some hospital systems. We think it has something to do with I.T. blocks on some php forms like this but not sure. We prefer that you use this form, but if not just download and use the PDF. You can always call us at 01-614-883-1739.