Registration Form For All Listed Courses

Please fill out the form below. To ensure proper identification, make a computer copy of this form, enclose your payment, and mail to: Coleman Education Opportunities, 2812 Harrington Rd., Simi Valley, CA 93065. Confirmation will be sent either by email or regular postal mail. Make checks payable to: Coleman Education Opportunities. We appreciate your business.

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Please provide the following registration information:

Name

Title (e.g. MD,RN,RRT)

Site & Area Employed

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Country

Work Phone

Home Phone

FAX

E-mail

Choose one of the following courses:

Course Location and Date:

Date Location of Course

Registration Fee ($):

Single/Couple Amount Enclosed ($)

Purchase the American Heart Association ECC 2000 Handbook Now! Just add $17. to your Registration Fee. The Handbook will be mailed to you. Allow 5-7 working days for delivery.

Name
Title (e.g. MD,RN,RRT)
Site & Area Employed
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

Registration Form For All Listed Courses

Coleman Education Opportunities, 2812 Harrington Rd., Simi Valley, CA 93065Copyright © 2000 [Coleman Educational Opportunities]. All rights reserved. Revised: April 17, 2005

Coleman Education Opportunities, 2812 Harrington Rd., Simi Valley, CA 93065
Copyright © 2000 [Coleman Educational Opportunities]. All rights reserved.
Revised: April 17, 2005