Beck Consulting Advanced Workshop                 September 2022
Event Dates: September 29 & 30 2022
Event Address: Avantik - 19 Chapin Rd Building C, Pine Brook, NJ 07058
Contact us at (828)369-2315 or Beckconsulting.us@gmail.com

Below is the Registration Form for 2 Day Advanced Workshop.  This training has been approved for accreditation through the National Society for Histotechnology.

*A form needs to be completed for each technician registering.  Upon receipt of your completed registration, you will receive an invoice via email.  Please remit payment for the workshop through the link provided to you. REGISTRATION is NOT Complete until payment is received and confirmed by us.

*Hotel Booking Link:https: www.my-event.hilton.com/beckconsultingseptember/

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Email *
Mohs Technician Name *
Email Address *
Mohs Surgeon Name *
Office Name *
Office Address *
Office Phone Number *
Full Name (as you want printed on Certificate and Badge) *
Best Contract # while traveling (should we need to reach you during your stay with us) *
Will you be staying at the Hotel with us? *
Will you use the Shuttle to and from the Hotel to Workshop *
Emergency Contact Name *
Emergency Contact # *
Do you currently work in a Mohs Lab? *
How long have you been cutting Mohs? (Write N/A if does not apply) *
How many cases (estimated) do you cut a day? (Write N/A if does not apply) *
Dietary restrictions *
Early Registration Fee before September 5: $1000 (Per Tech)  - $1800 (2 Techs)                                                             *
Required
Invoicing Information Need:                                    *Contact Name                                                                                    *Contact Email                                                                                   *Contact Phone *
A copy of your responses will be emailed to the address you provided.
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