2010 Registration

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Education Seminar Registration Form

Please fill out the following form. All fields are required.

First Name: *

Last Name: *

Title: *

Registry Number (If Applicable):

Hospital: *

Address: *

City: *

State: *

Zip: *

Telephone Number: *

Fax Number:

Email: *

PrePay Package (See policies above): *

Sales Order (if Known):

Billing Address: *

Billing City: *

Billing State: *

Billing Zip: *

Current Equipment (Manufacturer/Model): *

If Other, describe:

Special Requests and Comments:

Please check how you would like to receive your confirmation: *

Fax

Letter Mail

Please make sure to reserve your hotel room 30 days prior to class start date. **Please see the new amenities and lower rate offered by the Hilton Arlington Hotel on our Location and Lodging page.

(read before submitting your registration)

PrePay Packages will be confirmed with our records to ensure proper billing. Education Package Owners: You will be contacted for Credit Card information to reserve space in the course. There could be a surcharge for registrant no shows.
Confirmation is based on a first come first serve basis. Enrollment may be denied at anytime if and when maximum course registration has been met. You will receive confirmation within 3 business days from receipt of registration. Early registration is highly recommended to ensure availability.
Attendance will be guaranteed only after receipt of registration form and confirmation of available space.
All confirmed registrations are NON-REFUNDABLE. Cancellations later than three weeks or no shows may result in an assessment of a full course fee to the credit card on file or loss of course on education package. Charges will apply regardless of whether or not a current education package exists. Non-refundable course fees may not be applied towards other courses. Submission of registration indicates acceptance of policies.
Confirmation of your acceptance into the course, is pursuant to the above policies.
We accept Visa Mastercard and AMEX

By clicking "Submit", you agree to the above policies and terms.

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