THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY
Printed Date: 3/29/2024 7:58:28 AM
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Seminar Title: |
5-Day Certificate Program Retreat: Attachment-Centered Play Therapy in a Retreat Setting |
Seminar Date: |
Sunday, August 26, 2018 |
Seminar Location: |
PINE KNOLL SHORES, NC 28512 |
Seminar ID: |
63589 |
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Required (select one) |
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EARLY BIRD REGISTRATIONS AVAILABLE THROUGH JULY 13, 2018
Single Occupancy
$1,799.00 By July 13, 2018
$1,999.00 After July 13, 2018
Double Occupancy
$1,599.00 By July 13, 2018
$1,799.00 After July 13, 2018
BONUS: Get a FREE IATP membership by attending! A $99.99 value, plus waiving the $99.99 application fee for Certification! Completion of this 5-day retreat meets the educational requirements when applying to become a Certified Child and Adolescent Trauma Professional (International Association of Trauma Professionals,
www.traumapro.net)
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________ HI, NM attendees add applicable sales and local taxes**
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________ Subtotal (Required items + sales tax)
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Optional |
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________ AL, AR, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NJ, NM, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY attendees add applicable sales and local taxes**
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________ Subtotal (Magazines + Optional items + sales tax)
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________ Total (Required subtotal + Optional subtotal)
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** Tax-exempt customers please send a copy of your tax-exempt certificate.
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*** Registration for coordinator or military member discount must be completed online
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**** All prices are shown in US Dollars ****
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Please enter the MAIL CODE in the box below.
If you have a brochure, this code is found on the back in the box above the address block.
If you do not have a brochure, please enter 888.
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Last Name:
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Note: Leave Company/Department blank if providing home address |
Company Name: |
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Department: |
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Address: |
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City: |
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Work Phone: |
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Cell Phone:
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Fax Number:
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Email Address: |
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License Number: *
(required for confirmation of registration)
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Prepayment is REQUIRED |
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Check enclosed
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Signed Purchase Order enclosed
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Credit Card Type: |
Mastercard
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Amex
Discover
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Credit Card #: |
V-Code #*
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Exp Date: |
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*MC/Visa/Discover: last 3-digit # on signature panel on back of card |
*American Express: 4-digit # above account # on face of card |
Name on Card: |
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Mail or Fax to:
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PESI Rehab, P.O. Box 1000, Eau Claire, WI 54702-1000 (800) 554-9775 (fax number) |