To expedite your registration you can email your information using this form.  Please read all instructions carefully.  Incorrect or omitted information is your responsibility and may invalidate your registration.

TO REGISTER: Fill in the blanks on your screen (online) by using your mouse and/or tab keys to navigate, type in your information, and hit the "Submit Your Information" button at the bottom of this form.

WE DO NOT TAKE PAYMENTS ONLINE!

YOU MUST STILL COMPLETE THE FORM ON THE HOME PAGE AND MAIL PAYMENT.

This email option is intended to reserve a seat on short notice and update the class roster.

The attendee license number is mandatory to obtain proper credit on your completion certificate.  If the attendee is unlicensed and attending this class for credit put "Not Licensed" or "NL" in License #.   If you are an unlicensed attendee who will be submitting these hours for credit toward licensure, it is best if you enter your name below in the same manner you will use when applying for a license... example: John S. Smith

Licensee Name:        License #:

Class Requested:      Use Arrow On Right - Highlight Choice And Left Click ---------------------------------------------------------------------- December 04, 2013 (Wednesday) - Goldsboro, NC December 05, 2013 (Thursday) - Winston Salem, NC December 12, 2013 (Thursday) - Morganton, NC ----------------------------------------------------------------------

Number To Attend:    Use Arrow On Right - Highlight Choice And Left Click 1 Licensee   = 1 X $120.00 = $120.00 2 Licensees = 2 X $120.00 = $240.00 3 Licensees = 3 X $120.00 = $360.00 4 Licensees = 4 X $120.00 = $480.00 5 Licensees = 5 X $120.00 = $600.00 6 Licensees = 6 X $120.00 = $720.00 7 Licensees = 7 X $120.00 = $840.00 8 Licensees = 8 X $120.00 = $960.00 9 Licensees = 9 X $120.00 = $1080.00 10 Licensees = 10 X $120.00 = $1200.00 11 Licensees = 11 X $120.00 = $1320.00 12 Licensees = 12 X $120.00 = $1440.00 13 Licensees = 13 X $120.00 = $1560.00 14 Licensees = 14 X $120.00 = $1680.00 15 Licensees = 15 X $120.00 = $1800.00 16 Licensees = 16 X $120.00 = $1920.00 17 Licensees = 17 X $120.00 = $2040.00 18 Licensees = 18 X $120.00 = $2160.00 19 Licensees = 19 X $120.00 = $2280.00 20 Licensees = 20 X $120.00 = $2400.00 21 Licensees = 21 X $120.00 = $2520.00 22 Licensees = 22 X $120.00 = $2640.00 23 Licensees = 23 X $120.00 = $2760.00 24 Licensees = 24 X $120.00 = $2880.00 25 Licensees = 25 X $120.00 = $3000.00

If you have more than one licensee ATTENDING THE SAME CLASS, you may register one licensee with the information above and put the remaining attendees in the box below.

If the licensees are attending different classes you should complete separate registration applications.

License number is mandatory in all cases!  If the attendee is not licensed you should put Not Licensed.

When using the box below, please put the Licensee Name followed by a comma and then the License Number. For example: John Smith, 12345 OR John Smith, Not Licensed.  Failure to use the correct format may create a problem with the data set when emailed.

You may put any comments, notes or pertinent information about the class or licensees in the box.  There is unlimited space, so please be descriptive when providing information other than names and license numbers.

Use the scroll bars if you need additional space in the box.