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Registration Form

Continuing education certificates will only be awarded to participants who attend an entire program.**

** In addition to the $200.00 registration fee, there is a $10.00/participant charge for AzPA to issue continuing education certificates to the participants wishing Behavioral Health CE credits.

First Name: *

Last Name: *

Home Address: *

City, State, Zip:

Place of Employment: *

Occupation: *

Contact Phone Number: *

Email Address: *

Date(s) needed: April 30, May 1, Both: *

April 30

May 1.

BOTH

Type of Continuing Education Credits Needed: *

Social Worker CE

AzPA CE

Nursing CEU

Physician CME

Physicians Assistant CME

General

None Needed

Please select the type of CE/CME units needed

Payment Options:

Check

Money order

Purchase order

Credit Card

Select a payment type.

Name on Credit Card:

Credit Card Number:

Credit Card Type:

Visa

MasterCard

Discovery

Expiration Date:

Amount Authorized:

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