Your information is secured using GeoTrust technology to
Call
646-207-9934
for registration price or email this form to obtain more information. You will receive an email confirmation and enrollment fee before your card is charged.
Nemrac Infusion Technology, Inc.
2202 Cedar Avenue, Suite #2, Bronx, NY 10468
Cancellation/Refund policy: Registration fee: $100.00(non-refundable). All cancellation must be made at least 14 days prior to start of program. A $100.00 administrative fee will be charged for all cancellations and refunds. Non-attendance leads to forfeit of all monies or registrant must attend another seminar. A return check fee of $25.00 will be charge.
First Name
* Required
Last Name
* Required
Street:
* Required
City:
* Required
State:
---USA---
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
* Required
Zip:
* Required
E-mail:
* Required
Work Phone:
* Required
Home Phone:
* Required
Location:
* Required
Date:
* Required
Number of Registrants:
* Required
Credit Card:
Visa
MasterCard
American Express
Number:
Exp. Date:
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2004
2005
2006
2007
2008
2009
2010
2011
2012
Cancellation/Refund policy: Registration fee: $100.00(non-refundable). All cancellation must be made at least 14 days prior to start of program. A $100.00 administrative fee will be charged for all cancellations and refunds. Non-attendance leads to forfeit of all monies or registrant must attend another seminar. A return check fee of $25.00 will be charge.
