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Name
Instructions
This information is used to create the participant CME/CEU paperwork, contact the participant directly (if necessary), and send materials (if applicable).
First Name*
Middle Name
Last Name*
Credential The license or certification you want to appear on your paperwork (Ex: MD, RN, CHT). DO NOT include your name here.
License/Certification Your license or certification. Choose all that apply. This selection does NOT appear on your paperwork - it is only used to determine the type of CME/CEU you will receive.
NURSES ONLY - State & License # NURSES MUST provide a license number for CNE credit (eg: TX 123456)
CHT ONLY - certification # If you do not have CHT certification, leave this field blank.
Email & Password
Please use your personal email address. Some hospital emails block incoming messages from us.
E-mail*
Password*
Repeat Password*
Billing Address Instructions
Please enter the name and billing address associated with the credit card you will use for this purchase.
- Billing Address
- Country*
- First Name*
- Last Name*
- Company Name
- Address*
- Address 2
- Town / City*
- State / County*
- Postcode / Zip*
- Email Address*
- Phone*
Shipping Address Instructions
Please enter a HOME shipping address. Materials might not reach the participant if shipped to a hospital address.
- Ship to a different address?
- Shipping Address
- Country*
- First Name*
- Last Name*
- Company Name
- Address*
- Address 2
- Town / City*
- State / County*
- Postcode / Zip*