This form will complete the registration process and securely accept your payment. Registering takes less than 3 minutes. All fields are required
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What is your first name? *

What is your last name? *

Do you understand that you need to be online paying attention for the duration of the course? (We are required to ask this question) *

It is required by the division of Professional Licensure that you complete the entire 40 hours. If you cannot complete the four 10 hour sessions, you will not be eligible to receive a certificate.  If you are unable to be present for all four sessions,
would you like to register for a different course? *

Which upcoming course would you like to register for? *

Please give us your telephone number so we can better understand and try to accommodate your situation. *

Is {{answer_55513645}} {{answer_55513648}} the name you want to appear on your certificate of completion? *

Please enter the full name you would like to appear on your certificate. *

Your credit card will be charged {{var_price}} today. Please enter your credit or debit card information below. *

Please enter your Credit or Debit Card number: *

The CVC number: *

(3 or 4 digit security number on the back of your card)
The name on your card: *

Your card's expiry month: *

Your card's expiry year: *

What is your current mailing address? *

(insert complete address)
What is your telephone number? *

(if we have any questions or need to contact you)
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