Registration Form - Professional and Continuing Education

2015 CCEMTP(SM) CONTINUING EDUCATION REGISTRATION
FOR
CURRENTLY CCEMTP(SM) CERTIFIED
Registration Fee: $100.00 per day
PLEASE SELECT PREFERRED COURSE DATE(S) – LIMIT
Monday, July 13, 2015
Tuesday, July 14, 2015
Wednesday, July 15, 2015
Friday, July 17, 2015
Saturday, July 18, 2015
FIVE (5) DAYS
Monday, July 20, 2015
Tuesday, July 21, 2015
Thursday, July 23, 2015
Friday, July 24, 2015
Continuing Education Credit
This continuing education activity is approved by UMBC, an organization accredited by the
Continuing Education Coordinating Board of Emergency Medical Services (CECBEMS).
Please type or print clearly. A confirmation packet will be sent upon receipt of registration and payment.
Mail this completed form and your check made payable to "UMBC" to:
University of Maryland, Baltimore County
Dept. of EHS/PACE
1000 Hilltop Circle, Sherman Hall, Room 316
Baltimore, Maryland 21250
OR
fax your registration form with credit card information to (410) 455-6713.
Name:
Email:
Address:
City, Sate, Zip:
Phone:
NREMT-P/Paramedic Lic #:
RN, MD License #:
Student #:
Alternate Phone:
Exp. Date & State:
Exp. Date & State:
# of Days
Continuing Education Daily Fee
$ 100.00
Enclosed is my check in the amount of
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Please charge my VISA MasterCard (please circle one) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Credit Card Convenience processing fee (add to balance above)
TOTAL AMOUNT TO BE CHARGED>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
Card
Number:
Address if
different
from above:
V-code:
Enter Amount
$
5.00
Expiration Date:
(last three digits on back of card)
Name as it appears on Card:
Signature:
Cancellations/Refunds
subject to a $45.00 withdrawal fee. After the
withdrawal deadline all tuition will be forfeited.
refunded or transferred to another course
date at UMBC's expense.
For Office Use Only
T-Code: 410 Fund Code: 1113 Prog Fin: 000 Department: 10556 Account: 4873372 Project: CV390043 Actv ID: CNV Resc Type: OPREV
Revised 6/15
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