AMERICAN INSTITUTE OF HEALTH CARE PROFESSSIONALS
American Institute of health care professsionals
CEU Course for Re-Certification
Application for COURSE REGISTRATION
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|Personal Information |
|Full Name: | |
|E-MAIL ADDRESS: | |
|Mailing Address: | |
|City: | |
|State: | |
|Zip Code: | |
|Phone Number with Area Code: |( ) |
|Fax Number with Area Code: |( ) |
|COURSE SELECTION |
|COURSE TITLE: | |
|Cost of Course: | |
|Today's Date: | |
|My Certification Specialty is: | |
|Are you Currently Certified by | |
|one of the Specialty divisions | |
|of AIHCP? | |
|This registration form must be completed fully to properly enroll into a CEU Online Course. Upon completion, please be sure to |
|click the "submit" button at the bottom of this form. |
|Please Provide the Following Information |
|Organization or Certifying Body | |
|you are currently certified by: | |
| |[pic] |
|Date of certification | |
|(mm/dd/yy): | |
|Date of expiration (mm/dd/yy): |[pic] |
|Payment Information |
|We accept the following major credit cards: Visa, Master Card, And American Express. If you would like to postal main in your CEU |
|Course registration, DO NOT complete and submit this electronic form. Rather, please access the link above for "PRINTABLE |
|REGISTRATION FORM." You may print out this registration form and postal mail your registration and payment. By postal mail, you may|
|pay by check, money order (payable to: AIHCP) or by providing credit card information on the registration form. |
|Method of Payment |
|CARD NUMBER: | |
|Expiration Date: |[pic] |
|NAME ON CARD: | |
|Please select a Credit Card: |[pic]VISA |
| |[pic]MASTER CARD |
| |[pic]AMERICAN EXPRESS |
|Agreement |
|I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual |
|and true. I understand that failure to provide the needed information and required documentation could likely lead to delays in the|
|processing of this application. |
|By clicking the "submit" bottom below, I acknowledge that I understand that the course or courses I am registering for are |
|continuing education courses and that upon successful completion of the course (s) I will be awarded and receive a CEU certificate |
|with the corresponding hours of awarded education. I understand that AIHCP is not a school, and that the course(s) I am registering|
|for are neither college courses nor are they intended for any type of transfer credits to any schools or colleges/universities and |
|will not be accepted toward any type of college degrees. I further understand that the cost of course tuition does not include any |
|required textbook and I am responsible for securing my own textbook. I further understand that I have two full years from the date |
|of official enrollment into a course, to complete the course. |
|SIGNATURE: ____________________________________Date: _____________________ |
|MAIL THIS COMPLETED APPLICATION TO: |
| |
|American Institute of Health Care Professionals, INC. |
|2400 Niles-Cortland Road, S.E., Suite # 3 |
|Warren, Ohio 44484 |
| |
| |
| |
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