P.O. Box 40088
Philadelphia, PA  19106-0088
(215) 627-5306  Fax: 215-627-2754
Workshop Registration Form

  Last Name                                                              First Name  
 
  Home Address  
         
  City                                                                                State                           Zip Code          
   
  Home Phone                                                                  Cell Phone
 
  Employer                                                                                                            Member Code        
       
  Employer Address             
 
 City                                                                                   State                         Zip Code 
      
 Work Phone                                                            Ext.              Work Fax            
 
  E-Mail Address
 

  Please enter the ID#, Title, and Date of the session for registation. If you require 
  CE/CLE/CPE Continuing Education Credits, please add  $10 per certificate.

   If you require PA CE credits, please add an additional $7.00 for each workshop. If you require 
  PA CLE credits, please add an additional $5.00 for each half day and $9.00 for each full day workshop.
                                                                                                                 
                                                            Session                             Certificate     PA CE/CLE
    ID #          Title                                Date           Tuition             Fee                Fee                   Total        
                     
                      
                      
                        

                                                                                                                         Total Due    

If paying by credit card, please enter the information below or call us at (215) 627-5306 to provide us with the card information.

         Credit Card Type     Credit Card #                                    Exp. Date          Total to Charge
             

  Please enter any comments here                                                                                           
 
  CANCELLATION POLICY:  No refunds will be issued for a cancellation received later than 
  five days prior to the date of the workshop.  No credits will be issued for cancellations the day 
  of class or after the class has taken place. A non-refundable processing fee of $20.00 will be  
  deducted from all refunds and requests for workshop changes.

 Payment must accompany registration.