JEM EDUCATIONAL SERVICES
SESSION REGISTRATION FORM 2010
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___ Session XXXII July 9th - 11th
Make Check/Money Order Payable To:
JEM Educational Services
271 Ott Street, Suite 24
Corona, CA 92882
(951) 737-8433
PLEASE PRINT
Permit # RH______________
Name: _______________________________________________________________
Last First MI
Address: _____________________________________________________________
Street City State Zip
Contact phone: ( )___________________________________________________
E-mail address: ________________________________________________________
Profession: _____Urgent Care _____Industrial Clinic _____Imaging Center
_____Hospital _____Other
***Mail this Registration Form to the address listed below***
"Basic Digital Acquisition and Display for Operators"
*Confirmation of session will be phoned or emailed to you.
Please write your full name as it appears on your permit.
2010 Scheduled Dates
*Please mail this form with fee*
$10.00 Charge for cancellation prior to 10 days of scheduled session
$100.00 Charge for cancellation within 10 days of scheduled session
For Credit Card payments please contact JEM ($10.00 convenience fee applies)
$450.00 Early Registration with Permit
$500.00 Early Registration without Permit
$500.00 Late Registration with Permit
$550.00 Late Resgistration without Permit
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(Payment is considered late if received within 10 days of session)
Payment Enclosed:
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