WorkCompCentral Education Enrollment.pdf

M.I. Last Name:
Address: (include apt, unit, suite)
City: State: Zip Code:
Email Address: Telephone Number:
Profession Information:
Insurance: TPA: Self-Insured: Legal: Medical: Agent: Other:
Payment Information:
Name of Cardholder: (company or individual)
Payment Method: Check Visa MasterCard AMEX Invoice
Card Number: Expiration Date:
Signature of Cardholder:
WorkCompCentral Education Policy:
Refunds are granted only if requested in writing and postmarked, faxed or e-mailed no later than 7 days prior to the live seminar date. A $25 administration fee will be imposed on all refunds. No refund will be approved if you fail to attend a live seminar or fail to cancel your course reservation. No refund will be approved if you are not satisfied with an online course, we will credit the full course price toward any other course we offer prior to course completion and prior to the attainment of any applicable continuing education units or certificate of completion.
If invoiced, payment must be received within 21 days.
Course Enrollment Information:
Course Name: Start Date: Cost:
Course Name: Start Date: Cost:
Course Name: Start Date: Cost:
Course Name: Start Date: Cost:
Course Name: Start Date: Cost: _