REGISTRATION FORM

 Print and fax form to 217-787-6020 or mail it to Critical Care Ed, 6701 Bunker Hill Rd, New Berlin, IL 62670.   We will e-mail you the access code for the course you are enrolling in.

 Name:_________________________________________________________________________

Position/Title:____________________________________________________________________

 License #:______________________________Last 4 Digits of SSN #___________________

 Institution:______________________________________________________________________

 City/State/Zip:___________________________________________________________________

 Home Address:__________________________________________________________________

 City/State/Zip:___________________________________________________________________

 Phone (H):_______________________________ (W)___________________________________

 E-mail:_______________________________________________________________________

 Master Card Visa American Express

 Card #:_______________________________________________________

     Expiration Date:________________________________

  Pay by check (Please make payable to "Critical Care ED" and mail to Critical Care ED, 6701 Bunker Hill Rd, New Berlin, IL 62670  

Select from the following programs:                                

  Course Books available:  (These books are not mandatory to take the online courses) 

  Total amount you are paying by check or to be charged to your credit card $_____________

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