REGISTRATION FORM

NBCOT CERTIFICATION EXAM REVIEW COURSE

AT SUNY DOWNSTATE MEDICAL CENTER

Saturday, January 25, 2014 – 8:30AM– 5:00 PM

Sunday, January 26, 2014 – 9:00AM – 5:00 PM

Early Registration Fee (if postmarked before December 15, 2013):  $250.00

Registration Fee: $250.00

Late Registration Fee (postmark after January 6, 2014): $300.00

Make checks payable to SUNY-IFR #900069-01 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 29, 2014: ___________________________________

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, 2014..

If we receive your registration form and payment AFTER the maximum number of 55 participants has been reached, we will inform you by e-mail and we will return your registration form and check via postal mail