CTR Exam Preparation Workshop
Online Registration Form
 

If your employer is paying for the course and cannot pay with a credit/debit card, check the appropriate block at the bottom of the form.  Full payment is due upon registration if being paid by the registrant.  If the fees will be paid by an employer (check the appropriate block in the form below.  Payment by your employer must be received within 2 weeks of registration or 7 days before the class, which ever is sooner, to ensure your class seat is not lost. 

Date/Location of Course*                             *Denotes required items

Name*  
Facility*    (hospital, company, or "none")
Address*
 		  
 
City*       State/Province*       Zip/Postal Code*    
Daytime Phone*   -   -    ext
Home Phone   -   -    (for use in case of weather-related or other emergency)
FAX Number

  -   -  
E-mail address*  

  Check here if you will bringing a laptop with electronic reference materials for classroom use.

Note any dietary restrictions (vegetarian, kosher, etc):   

How many years have you been a registrar?*                           
 

   Check here if payment will be sent by by the facility indicated above.
         (When you get to the online payment page, just close your browser.)
         Make check payable to:   A.Fritz and Associates, LLC
                                               21361 Crestview Road
                                               Reno, NV 89521
 

Please be sure all information is correct before proceeding to credit card payment