PROFESSIONAL MEDICAL EDUCATION ASSOCIATION, INC.
USE THIS PAGE TO ELECTRONICALLY REGISTER FOR SEMINARS.
Credit Card Payments accepted below. Checks are made to Professional Medical Education Assn,
            and mailed to:  PO Box 997, Grove City, OH 43123.
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 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 24 hours.

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.
* Indicates required information:                     v2408
* Name
as you would like it to appear on the Certificate, including "RN", "MD", "CST" etc.
    (complete a separate form for each person registering)
Title/Dept
Company/Hospital
* Mailing Address
Where Certificate
will be mailed.
Home Address
Work Address
* Registratnts Email
Confirmation, and any course materials will be sent electronically via email to this address, in addition to any course status updates.
Watch for emails from "Hightail" in your Spam folder.
* Confirm Email
* Phone
* Seminar
 
Remarks? or
Requests?
* Payment Method:
*Enter either Purchase Order # or Credit Card Info
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 supercedes any terms listed in our purchase order.
Credit Card
Card Number:
Cardholder Name:
Expiration Date
3 or 4 Digit Security Code on back:
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
Please type the txt into the box
If I am paying by credit card, I hereby authorize charges to my card for the item(s) ordered
After you SUBMIT your order we'll followup within 24 hours after we've processed your registration.
All registrations are manually processed by staff.
mm/yy
Choose the Correct Course.
If prepaid discounts, "early bird" registration, and/or Bonuses are provided, that will be reflected on your invoice or actual credit card charge.
PLUS - type in the course date & city below for clarification:
* Course Date & City
Add a copy of the current ANSI 136.3 Standards ?
Provided at course.
YES. Add a set of standards. These are optional.
$170     (American National Standards Institute -
   Z136.3 Safe Use of Lasers in Health Care Facilities)
  Only 1 copy is required per facility, not per person. Primarily for LSO courses.
(Also available separately from courses from the pull down list above. Standard 3 day shipping & handling charges apply if ordered separately from a course.
* NCLC Laser Certification?
YES.
Do you plan on taking the NCLC Laser Certification Exam offered at this course, if offered? (No additional fee)

Call us if you want to take more than one type of exam.

NOTE: You MUST request the Certification exam either at the time of registration, or no later than one week prior to the course, in order to have an exam available for you to take.
NO
Must include Area Code & Phone # for US numbers.
Use format of 5554441212 - no spaces, hyphens or dots
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