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 : [email protected]
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 .
_____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Signature Date
____________________________________________________________________________________
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 ____________________
____________________________________________________________________________________
PITS & Corexcel Training Services website : Professionalivtraningservices.webbly.com
PHONE ( 302 ) 229-6467 Email Address : [email protected]
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 .
_____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________
Signature Date
____________________________________________________________________________________
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 ____________________
____________________________________________________________________________________