the USLCA recorded webinar order form

More documents

Recommendations

Info

2. □ 1 hr. December 8, 2009 "The Role of the Breastfeeding Father" presenter Tom Johnston, CNM, IBCLC ___ Quantity □ Individual □ Group of 3-10 □ Group of 11 or more 3. □ 1 hr. June 9, 2011 "Teaching the Oxytocin-Enriched Brain: Getting it "Right" so Moms Can Hear You" by Dawn Kersula, RN,FACCE, IBCLC ___ Quantity □ Individual □ Group of 3-10 □ Group of 11 or more Webinars with Cerps Not Offered: 1. □ 1 hr. August 16, 2012 “Reimbursement 101” by Gini Baker, RN, MPH, IBCLC, Judith Gutowski BA, IBCLC Cerps not offered for this webinar. Shipping and Handling fee is $10.00 members and 35 for Non – Members. 2. □ 1 hr. August 23, 2012 “Getting Started with Aetna” Speakers: Shannon Montgomery and Jenee Dederichs Cerps not offered for this webinar. Shipping and Handling fee is $10.00 members and 35 for Non – Members. 3. □ 1 hr. October 25, 2012 “Marketing Imperatives for IBCLCs” by: Bettina Forbes, CLC & Danielle Rigg, JD, CLC Cerps not offered for this webinar. Shipping and Handling fee is $10.00 members and 35 for Non – Members.
Please submit this form with payment and the above order form. We will not process incomplete order forms. Name: ___________________________________ Email: _______________________________ Address: ______________________________________ Phone: __________________________ City: ________________ State: __________ Zip Code: _____________ If you would like to send a check, fill out the information below and please mail payment to: Check #_______ Amount on Check: _______ USLCA Webinar 2501 Aerial Center Parkway, Ste. 103 Morrisville, NC 27560 If you would like to pay with a Credit Card please complete the below information: Type of Credit Card: □ Visa □ Master Card Credit Card Number: __________________________________ Expiration Date: ____________ 3 digit CVC code: __________________ I authorize the USLCA to charge my Credit Card ___________ as payment for the webinar Signature: _____________________________________________________________________ If you are ordering for your chapter please list the Chapter name below ________________________________________________________________________________ Please submit this form and your payment by any of the ways listed below: Fax: 919-459-2075 Email info@uslca.org Mail: USLCA Webinar, 2501 Areal Center Parkway Ste. 103, Morrisville, NC 27560
Page 1 and 2: USLCA Recorded Webinar Order Form P
Page 3: 16. □ 1 hr. December 1, 2011 "Hum

the USLCA recorded webinar order form

Create successful ePaper yourself

Delete template?

Save as template?