Printable Registration Form

Registration Form

FREE SPOUSE REGISTRATION - Your non-professional spouse is invited to take your course with you for no additional registration fee.

PROFESSIONAL SPOUSE - Your professional spouse (MD, DDS, RN, RDH, etc.) may take any ASI course when you take your course. Registration fee is the higher single course fee plus $300.00 for your spouse.

DISCOUNTED REGISTRATION FEES - Receive a $25.00 to $100.00 tuition discount for any additional ASI courses taken within 12 months. Call for details.

NAME & DEGREE:___________________________________________________________

REGISTERING SPOUSE:______________________________________________________

OFFICE

ADDRESS:__________________________________________________________

CITY:_______________________________ STATE:_____ ZIP:________________

PHONE:___________________________ FAX:__________________________

E-MAIL ADDRESS:_________________________________________________________

DATES OF ATTENDANCE:________________________________________________________

SEMINAR LOCATION:___________________________________________________________

MEDICAL COURSES

Family Practice …………………$490.00 Urology Review ………………… $490.00

Internal Medicine ……………… $490.00 OB/GYN ……………………….. $490.00

Orthopedics ……………………. $490.00 Otolaryngology ………………… $490.00

Cardiology ……………………… $490.00 Emergency Medicine …………. $490.00

Pediatrics ……………………….. $490.00 Anesthesiology ………………….$490.00

General Surgery ……………….. $490.00 Gastroenterology ……………….$490.00

Psychiatry ……………………… $490.00 Oncology ……………………….. $490.00

Ophthalmology ………………… $490.00 Geriatrics ………………………. $490.00

Neurology ……………………… $490.00 AIDS/Risk Management & State

Trauma ………………………… $490.00 Requirements …………$490.00

OTHER CHARGES/DISCOUNTS

Professional Spouse …………………………………………$300.00

RN, Resident, RDH, etc. (if taking alone DEDUCT) …………$- Call

Previous Student Discount ….(call) …………………………$______

TOTAL FEES (US Funds) ……………….$_____________________

REGISTRATION FEES INCLUDE COURSE MATERIAL, CREDIT PROCESSING FEES, DOCUMENTATION, TAXES

AND REGULAR SHIPPING CHARGES TO ANYWHERE IN THE CONTIGUOUS STATES.

CANCELLATION POLICY: You may cancel 21 days or more prior to your start date and receive a full refund less a $35.00 per person non-refundable administrative fee. Cancellation within 21 days may also include shipping charges ASI may have incurred. You may avoid cancellation fees by putting your course on hold to be taken at any date within 12 months.

PAYMENT: CHECK VISA MC AMEX AMERICAN SEMINAR INSTITUTE

P.O. BOX 1400

CARD# _______________________________ CARBONDALE, CO 81623

(970) 963-1000 FAX (970) 963-9112

EXP. DATE ____________________________ 8 AM TO 5 PM (MST) Monday - Friday

CARDHOLDER NAME _____________________ Security Code____________

(Last 3 Digits on back of card;

SIGNATURE _____________________________ Amex 4 digits on front right side

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