| Personal Information |
Full Name:
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| Email: |
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| Mailing Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone (Area code - Number): |
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| Fax (Area code - Number): |
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| COURSE
SELECTION |
| COURSE
TITLE: |
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| cost
of Course: |
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| Today's
Date: |
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| My
Certification Specialty is: |
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| Are
you Currently Certified by one of the Speciality divsions
of AIHCP? |
Yes
No |
| This
registration form must be completed fully to properly
enroll into a CEU Online Course. Upon completion, please
be sure to click the "submit" button at the bottom
of this form. |
| Please
Provide the Following Information |
| Organization or Certifying Body you are currently certified by: |
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Date of certification (mm/dd/yy): |
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| Date of expiration (mm/dd/yy): |
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Payment
Information
We accept the following major credit cards:
Visa, Master Card, And American Express. If you would
like to postal main in your CEU Course registration,
DO NOT complete and submit this electronic form.
Rather, please access the link above for "PRINTABLE
REGISTRATION FORM." You may print out this registration
form and postal mail your registration and payment. By
postal mail, you may pay by check, money order (payable
to: AIHCP) or by providing credit card information
on the registration form. |
Method of Payment
Provide Credit Card Information ONLY if you are printing this form and postal mailing it to our office. |
| CARD
NUMBER: |
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| EXPIRATION
DATE: |
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| NAME
ON CARD: |
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| Please
select a Credit Card: |
VISA
MASTER CARD
AMERICAN EXPRESS
NOTE: if you are paying for a CEU Course by credit card, after clicking the submit button below, you will directed to a page with a link to use our secure online credit card server. |
Agreement
I, the undersigned, verify that this application is
complete, and to the best of my knowledge, all information
provided is factual and true. I understand that failure
to provide the needed information and required documentation
could likely lead to delays in the processing of this
application.
By clicking the "submit" bottom below, I acknowledge
that I understand that the course or courses I am
registering for are continuing education courses
and that upon successful completion of the course
(s) I will be awarded and receive a CEU certificate
with the corresponding hours of awarded education.
I understand that AIHCP is not a school, and that
the course(s) I am registering for are neither college
courses nor are they intended for any type of transfer
credits to any schools or colleges/universities and
will not be accepted toward any type of college degrees.
I further understand that the cost of course tuition
does not include any required textbook and I am responsible
for securing my own textbook. I further understand
that I have two full years from the date of official
enrollment into a course, to complete the course. |
| Your comments or questions: |
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