REGISTRATION FORM

NBCOT CERTIFICATION EXAM REVIEW COURSE

AT SUNY DOWNSTATE MEDICAL CENTER

Saturday, January 26, 2013 – 8:30AM– 5:00 PM

Sunday, January 27, 2013 – 9:00AM – 5:00 PM

Early Registration Fee (if postmarked before December 15, 2012):  $225.00

Registration Fee: $250.00

Late Registration Fee (postmark after January 6, 2013): $275.00

Make checks payable to SUNY-IFR #900069-02 and mail with completed form to:

CHRP Bursar, Box 11

SUNY Downstate Medical Center

450 Clarkson Avenue

Brooklyn, NY  11203-2098

Name: _______________________________________________________

e-mail address (for confirmation of registration) :  

_________________________________________________ 

Phone (day):  _______________________________________________

Phone (evening):  _____________________________________________

Mailing Address: _______________________________________________

                            ________________________________________________

University: __________________________________________________

Indicate if you are unable to attend on Saturday and wish to view videotapes of Saturday sessions on Wednesday, January 30,2013: ___________________________________

Amount of Check: _________________________

We will make every effort to ensure that our program is fully accessible to persons with disabilities.  If you have a disability that may impact upon your participation in this program, please send an e-mail describing your accommodation needs to ot.chrp@downstate.edu or call 718-270-7730. We will contact you prior to the course to discuss these accommodations.  To ensure the availability of accommodations, please send your correspondence BEFORE January 6, 2013..