Berkshire Area Health Education Center, Inc.

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Continuing Education Program Registration Form

 

Registration Form:
Name: _____________________ Address: ________________________
City/State/Zip: ___________________________________________________
Home Phone: _____________________ S.S.#

_________ - ______ - ________
Work Phone: _____________________ Email: ___________________________
Organization: _____________________ City/State: ___________________________
I Will Attend:
  ______________________________________________________________
  ______________________________________________________________

  ______________________________________________________________
Please check all that apply for CE Credit:

Nursing

SW

Other: ___________________ (please write out credentials)
Payment Options:

Enclosed is my check:

 $ _______________ 

Please bill:

____ MC          ____ Visa
Account #: ________________________________________________
Exp. Date: _____   /  ________ Amount:   $ _____________________
Signature: ________________________________________________
Please make check payable & mail or fax to:

Berkshire AHEC

703 West Housatonic St, #208, Pittsfield, MA 01201

Fax:  (413) 499-0370

Berkshire AHEC
703 West Housatonic Street,  Suite 208
Pittsfield, MA  01201

Voice:  (413) 447-2417
(866) 976-2432
Fax:  (413) 499- 0370

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