AHEC Registration

AHEC Class Registration

(all fields must be filled in, this will help ensure you are correctly registered)

phone must be in (xxx) xxx-xxxx format, zip code requires 5 digit only

Seminar Name:

Seminar Date:

Seminar Fee:

Student Name:

Address:

City: State: Zip Code:

County:

Daytime Phone: Evening Phone:

E-Mail:

Employer:

Job Title:

Employer Address:

City: State: Zip Code:

County:

Employer Phone: Employer Fax:

Professional Designation:

I authorize use of my credit/debit card: VISA Mastercard Discover

Card Number: 3-Digit V-Code*: Exp. Date:

Since it's hard to sign a web page, please indicate the month of your birthdate:

If you have questions or difficulty with this form, please call 870-391-3367
*(the 3 digit v-code is that silly little number on the back of your card)