Mail-In Registration Form

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             Name:_________________________

            Course Location and Date:___________________________________

            Home 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
P.O. Box 892752
Temecula, CA 92589-2752
Important:  Confirmation of registration will be mailed with pre-course material.

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