CEU 16 Hr Workshop Registration Form

PRINT AND FILL OUT THIS FORM:

PLEASE SEND A COPY OF THE COMPLETED FORM WITH YOUR CHECK TO:

FRANK J. PILEGGI, LMT

217 SUNSET DRIVE

WHITE OAK, PA. 15131

(412) 889-4107

PA LICENSE # MSG00004

NAME (AS IT APPEARS ON YOUR LICENSE) __________________________________________

STATE LICENSE NUMBER _____________________________

ADDRESS __________________________________________________________

(INCLUDE ZIP-CODE) __________________________________________________________

PHONE (INCLUDE AREA CODE) ________________________________________________

E-MAIL ADDRESS _____________________________________________________________________

16 HOUR IN-CLASS CONTINUING EDUCATION WORKSHOP:

DATES: NOVEMBER 9 & 10, 2024

TOTAL COST OF WORKSHOP IS $319.00

CHECK THE SPECIALS & DISCOUNTS TAB TO THE LEFT!

AMOUNT ENCLOSED: _______________________

PLEASE NOTE ANY SPECIALS HERE: _____________________