C.E. Registration Form

 

 

Name: ________________________________________________________________________________

 

 

Business Address: __________________________________________City: _________________________

 

 

Zip: ___________ Phone: ______________________ E-mail: _____________________________________

 

 

Profession: ______________________________ License #: ______________________________________

 

1.  Enroll me in The Law and Ethics Course November 7, 2003_______________________________________

 

2.  I want to belong to the __________________________________________________________________

                                                (Write the course you want to be in)

 

Day: _________________________________________ Time: ____________________________________

 

 

3.  I want to belong to the __________________________________________________________________

                                                (Write the course you want to be in)

 

Day: _________________________________________ Time: ____________________________________

 

 

I’m sending $ __________________ to reserve my place in this course(s). 

 

Credit Card Number: ________________________ Exp. Date: ____________ C.V. _____________________

[C.V. are the last three digits on the back of the credit card]