Registration Form for Self-Study Materials

Order and Disorder Registration Form

Please fax this form to 217.787.6020 or mail with full payment to: Critical Care ED, 6701 Bunker Hill Road, New Berlin, Illinois, 62670. Your materials will be shipped in 7 to 10 days. To contact us: 217.787.5937. Email: Lmoulton@cceconsulting.net. Make checks payable to Critical Care ED.

NAME:_____________________________________________________

POSITION/TITLE: ___________ LAST 4 DIGITS OF SS#:_________

INSTITUTION: ______________________________________________

INSTITUTION ADDRESS: ___________________________________

CITY/STATE/ZIP: ________________________________________

BILLING ADDRESS:

NAME: __________________________________________________

STREET ADDRESS/INSTITUTION: _________________________

________________________________________________________

CITY: __________________ STATE: ________ ZIP: ______________

PHONE: _______________

EMAIL (for receipt) ___________________________________

SHIPPING ADDRESS: (If shipping address different from billing address)

NAME: _________________________________________________

STREET ADDRESS/INSTITUTION: _________________________

________________________________________________________

CITY: __________________ STATE: ________ ZIP: ____________

PROGRAM(S): Please check the program(s) you wish to purchase

___The Basics Day 1……………………………………..$85.00
___The Basics Day 2…………………………………….$110.00
(Plus Shipping: ……………………………………………..$15.00

PAYMENT: __ Check ___ Credit Card

Amount: _______               ___ Mastercard ___ VISA ____ AM EX

Card Number: ______________________ Expiration Date: __________

Security Code ________