Name: ______________________________________________________   Date: __________

Address: ___________________________________________________________________

City/State/Zip:___________________________________________________________________

Cell Phone: _________________________________ Work Phone:__________________________

Telephone: __________________________________ Fax: ________________________________

E-mail address: ___________________________________________________________________

Organization (if any): ______________________________________________________________

Contact person (if any): ____________________________________________________________

Course Name: ______________________________________ Course Date: __________________

Course Name: ______________________________________ Course Date: __________________

Course Name: ______________________________________ Course Date: __________________

Total Amount Enclosed: $ ___________________________________________________________

How were you referred to NURSE MENTORS:

 Mail notice : Website : Flyer : Organization/Employer : Friend : Other _____________

ATTENTION: Please provide the name(s) of the selected training program, if participant(s) is/are registering for more than one training, please issue separate checks.

NOTE: Make check(s) or money order payable to:  NURSE MENTORS, INC.                                                        

Payment Method
 Cash  Check  Money Order  Credit Card (For credit card, please complete information below or call)

Name of Cardholder _______________________ Signature of Cardholder _________________________________________
Billing Address for Credit Card ___________________________________________
Acct. Number _________________________ Type: VS MC Discover Other ________
Verification code (on back of card) ______________ Expiration Date__________

FOR REGISTRATION & MAILING: Please mail ALL completed registration and payments to:

6161 MIRAMAR PARKWAY, SUITE 310, MIRAMAR, FL 33023

PLEASE NOTE:No fees will be refunded if this office does not receive written notice of cancellation five (5) business days prior to the start of training. Fees paid for training missed will not be applied toward any future training. SORRY NO EXCEPTIONS.

Nurse Mentors Educational Services reserves the right to refuse to provide training and/or professional services to non-compliant participants.

All training may be subject to date change or cancellation.

(copy of this form is accepted)