*First name

*Last name

*Home address

Home address 2

*City

*State

*Zip code

*RN/LPN License #   

*E-mail address

*Home phone

Name of employer

Work address

Work address 2

City

State

Zip code

Work phone

Fax

*Program Information

Enter: Program titles, program dates, program locations (city & state)

Payment Information

Verification of online registration will be emailed within 2 business days. Registration packet will be mailed to the home address above.

*Total tuition

*Credit card type

Visa

Mastercard

*Credit Card #

*Security Code #

*Expiration date

*Name on card

PCE member

Group rate: discount applies when preregistered and prepaid together

Group list (If you are part of a group, please list other people in your group)

Where did you hear about our programs?

Comments/Questions