Professional IV Training Services                          (302) 229-6467
 

   Regisitration Form To Be Copied and Printed  (Faxed)or (Email)

                                           September -December   2009 Workshops

PITS  & Corexcel Training Services                                           website : Professionalivtraningservices.webbly.com
          PHONE ( 302  )  229-6467                                                          Email Address : ivtrainingservices@gmail.com

        Please send copy of License and or Certification along with Identification that has to be verified for eligibilty of attending workshop....    
                                                
Name:  ( last ) ___________________ ( first ) ______________________   (middle) _____________________

Married  (      )      Single   (      )      Divorced   (      )                                        US Citizen: yes  (   )     No    (    )

Residence Phone: (_____) _____________________         Mobile Phone:(_____)     ______________________

 Email:   __________________________
 
Current Home Address ___________________   City /State _________________ Zip _________________

Mailing Address if Different    ____________________  City /State ________________   Zip ________________
Country:_________________


School Information: 
 High School / GED  ___________________  Address ____________________  City / State _________________Zip __________

 Graduation Date _____________

Trade School   _____________________ Address ___________________ City/State  ____________________  Zip __________

Trade Studies _________________________      Graduated    (      ) yes   (       )  NO         YEAR   ______________


College   ______________________   Address ______________________ City /State _________ _______ Zip _____________

Major_____________________    Minor ___________________      Graduated  (       ) YES     (        ) NO    Year ____________

Fellowship   ___________________     City /State _______________    Zip ______________


Are Currently Nationally Certified or License in the Medical Field ?      yes ( _____)    no ( _______)
If so please forward all verifiable  documents to be eligible to attend workshop... 



List of 2 Recent Employments : 

Employers Name ________________________     Address ___________________ City /State _________ __ Zip ____________

Supervisor Name ________________________  Position Held _________________     Duties ___________________________

Dates Started  From   ________ /       /__________       To    _________/       /__________


Employers Name ____________________    Address ___________________    City / State  ______________ Zip _________

Supervisor Name ____________________  Position Held ____________________  Duties ___________________________

Dates Started   From    __________/       /__________       To  ___________/       /____________


       Please write a short paragraph of why and how would you benefit from this I.V. Training Workshop .

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                                                                                                 _____________________________________________
                                                                                                               Signature                                                            Date


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Are you requesting Lodging because you qualified for a  Rooming  for workshop    ?             Yes   (        )      No     (      )
IF approved you will receive Hotel  Admit room ticket after your final payment is received.

 Signature of Applicate  ____________________         Date ______/       /__ _____                    Approved   (     )      Declined  (     ) 

                   Agent Signature  _________________________        Date Signed           ____________________
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