CCM Registration: PART 1

REGISTRATION: PART 1

Client Information

Associates: Click here to submit
your associate's fee.

You Must Complete Both Parts (Part 1 and Part 2) to complete your registration! After submitting this form, your will be redirected to Part 2 of the registration process where you will be able to submit payment with PayPal. You must complete both Part 1 & Part 2 in order to register!

*indicates mandatory fields

*Email Address :
*Confirm Email Address :
*First Name:
*Last Name:
*Address:
*City, St. Zip:
*Day Telephone '000-000-0000':
*Evening Telephone '000-000-0000':
Pager or cell phone (same format):
*Employer:
*Professional License Number:	or enter N/A
*Course Attending:
*Location / Training Facility:
Course Start Date* '00-00-10':
You must also read and understand the policy statement shown below before submitting this form: Company Cancellation / Refund Policy ...* In the event of a natural or manmade disaster, the registered participant may elect to choose another course date within the next twelve (12) months from the original training date or substitute another participant to take their place 72 hours prior to class without penalty. Cancellations for disasters will not be refunded. Refunds may be granted due to a death or severe illness within the participants immediate family with documentation and written notice postmarked prior to course date. A $75.00 administrative fee will be withheld. There will be NO REFUND for "no shows" which do not adhere to this policy. Refunds will be sent within 4 to 6 weeks from date of written cancellation. *Type "YES" (in all caps without the quotes) to 'Agree' with the above Policy: Enter the above validation code here: (Letters must be entered as CAPS) .