Full Name (required)

Street Address (required)

City (required)

State/Province (required)

Zip/Postal Code (required)

Country (required)

Telephone (required)

E-Mail Address 

Seminar/Location Dates (required)
(Note: $75.00 Reserves your seat)

Specify whether R.N. or V.N. (required)

Specify Package desired: Self-Study Manual or Memory Jogs  -- Assimilated Testings
(Note: No C.O.D. Orders -- Full payment due with order)

M/C Visa Other form of payment (e.g. mailing in by check or money order)

Cardholder Name

Cardholder's Relationship to Seminar Attendee

Card Number

Expiration Date

Amount to be Charged

Note: Personal checks, Money Orders, MasterCard and/or Visa accepted. Must be 7 days in advance with balance due the first day of seminar. 

Confirmation of Registration with the Location of Seminar will be mailed to you.

When paying by personal check/money order, copy the form and mail to:

CPS/Nurse Education
207 Allen Avenue
Glendale, CA 91201

Refund policy:  Cancellation up to 7 days will be refunded monies less $75.00 processing fee. Transfer of $75.00 will be allowed one time to attend alternate seminar. No refund or exchange on printed material.

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