JEM EDUCATIONAL SERVICES
SESSION REGISTRATION FORM 2008
Please indicate 1st and 2nd preference of session. Thank you.
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___ Session XIX January 23rd - 25th
___ Session XX
Special 2 day Session
January 31st - February 1st (Hawthorne, CA)
(Please contact JEM for details about the Hawthorne session)
___ Session XXI February 20th - 22nd
___ Session XXII March 20th - 22nd
___ Session XXII I April 17th - 19th
Print Registration Form
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
Payment Enclosed: ______ $450.00 Early Registration with Permit
______ $500.00 Early Registration without Permit
______ $500.00 Late Registration with Permit
______ $550.00 Late Registration without Permit
(Payment is considered late if received within 10 days of session)
***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.
*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)
2009 Scheduled Dates
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