Mail-In Registration Form
Name:_________________________
Course
Location and Date:___________________________________
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Address:__________________
______________________________
City:__________________________
State:__ Zip:_________
Phone:
(____)_____-__________ Fax:
(____)_____-__________
E-Mail:__________________
Facility:________________________
Address:________________________
_______________________________
City:___________________________State:__
Zip:________
Phone:
(____)_____-__________
Fax: (____)_____-__________
Circle one please: PT
OT MD
Please Enclose a check or money order payable to:
Pacific Therapy Education, Inc
Important: Confirmation of registration will be mailed with
pre-course material.
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