ONLINE REGISTRATION FORM

Please complete all required fields on this form and then
click the 'Continue' button to enter Credit Card Information.

>>> If you have questions about your registration please EMAIL: carolyn@uscap.org <<<

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Last Name: First Name:    Middle Initial:    Degree: Address: Phone:    FAX:    Email Address:

Course Fees: Academy Member   $ Academy Member in Training   $ Non-Member $ Non-Member in Training $ Click here if you are registering Sunday night and attending the reception: Accompanying persons are invited - please indicate total number attending:

		Will you have any special requirements when attending this meeting? If so, please contact Kerry Crockett with details: kerry@uscap.org
	After completing course registration and before you attend the course, you must take the online Pre-Test, accessible from the homepage, in order to claim CME credit.