CME/CEU Shorts 2018
Date: December 7, 2018: 8:30 - 12:00 Noon, 1:00 PM - 4:30 PM
Location: Krehbiel Auditorium, Luyken Fine Arts Center, Bethel College
300 E. 27th Street
North Newton, KS 67117
Name
Name as you wish it to appear on course certificate and name-tag. One registration form per person required.
First Name *
Your answer
MI
Your answer
Last Name *
Your answer
Organizational Affiliation/Title *
Your answer
Gender
Mailing Address
Street Address/PO Box *
Your answer
City *
Your answer
State/Province *
Your answer
ZIP (Postal Code) *
Your answer
Work Phone *
Your answer
Home Phone
Your answer
Cell Phone *
Your answer
Email Address *
Your answer
Registration Fee
$95 if received by November 16; $125 thereafter.
Refund Policy
If you must cancel your registration, do so as soon as possible. A refund, minus a $20 processing fee, will be made if cancellation is received no later than 4:00 PM, November 16, 2018.
Cancellation Policy
KIPCOR may cancel or postpone any training course because of insufficient enrollment or other unforeseen circumstances. If there is a cancellation or postponement, liability is limited to the registration fee.
Additional Registration Information
Lunch is on your own.
Special assistance required? If none, leave blank.
Your answer
Payment Options
Form of payment *
Checks made payable to KIPCOR can be mailed to KIPCOR P.O. Box 276, North Newton, KS 67117. Please call our office at (316) 284-5217 to make a credit card payment. Forms of credit accepted are Discover, MasterCard, and Visa.
Submit
Never submit passwords through Google Forms.
This form was created inside of Bethel College.