First
Name: |
Complete
this form online and submit it to us via fax, e-mail, or mail.
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Last
Name: |
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Degree: |
Ph.D., Psy.D., M.A.,
M.S.W. |
License
Type(s): |
Psychologist, MFT,
LCSW |
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| Company
Name: |
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License
Number(s): |
Ex.: PSY12345, MFT12345,
LCS12345 |
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| Address: |
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City: |
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| State: |
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Zip: |
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| Work
Phone #: |
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Cell Phone #: |
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| Fax
#: |
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E-mail: |
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Course
1: |
in
on
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| Course
2: |
in
on
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| Course
3: |
in
on
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| Course
4: |
in
on
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| Course
5: |
in
on
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| Course
6: |
in
on
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Home
Study Courses:
Registration: |
Please
send me the following courses:
1.
3.
2.
4.
Payment due at time
of registration. The sooner you register, the more you save! Tuition
includes written course material, morning muffins and/or bagels, beverages,
and a certificate of completion provided on-site after 100% attendance. |
Tuition
Schedule for our live C.E. courses:
The earlier
you register the more you save! |
EARLY: Paid 1 Calendar Month or More In Advance
Each six-hour one-day course: $149 x
courses = $
or 12-hour Child Custody Course: $495 x
courses = $
REGULAR: Paid Less Than 1 Calendar Month In Advance
Each six-hour one-day course: $159 x
courses = $
or 12-hour Child Custody Course: $545 x
courses = $
LATE: Paid 1-7 Days Prior or At-The-Door
Each six-hour one-day course: $179 x
courses = $
or 12-hour Child Custody Course: $595 x
courses = $
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| Independent
Study Programs |
Enter
the total here: $
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Discounts: |
Discounts
may not be combined. Not valid for home-study or child custody programs.
No retroactive discounts or adjustments.
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| Payment
Options: |
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Sub-Total: |
Enter
the sub-total here: $
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| Credit
Card Number: |
American Express=15 digits; Example:
1234-012345-01234 MasterCard/VISA=16 digits; Example:
1234-0000-5678-0000 |
Less
Discounts: |
Enter
discounts here: -$
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Expiration
Date:
Billing Zip Code: |
3 or 4-Digit Security Code:
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Total
Tuition: |
Sub-total
minus discounts: $
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Registration Options: |
Fax: Complete
this form online, print it,
and fax it to us at (714) 846-1164
On-Line: Complete this form online, save it as an Adobe PDF document, and e-mail it to us as an attachment.
Mail: Complete
this form online, print it, and mail it to: Psycho-Legal
Associates, Inc., P.O. Box 1458, Huntington Beach, CA 92647-1458
Phone: Call us at (800) 547-2736 between 9:30
a.m. and 4:30 p.m. PST.
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