Registration Form Ncic Rehabilitation Professional Mandatory Training printable pdf download

Registration Form Ncic Rehabilitation Professional Mandatory Training

REGISTRATION FORM

NCIC REHABILITATION PROFESSIONAL MANDATORY TRAINING

2 HOUR REFRESHER COURSE

Please check below the class you wish to attend. Class size is limited to 50.

______Thursday 2/18/16 9:30 AM to 11:30 AM (Deadline for receipt of registration fee 2/12/16)

One Renaissance Center, First Floor Conference Room

3301 Benson Drive

Raleigh, NC 27609

______Thursday 3/3/16 9:30 AM to 11:30 AM (Deadline for receipt of registration fee 2/25/16)

One Renaissance Center, First Floor Conference Room

3301 Benson Drive

Raleigh, NC 27609

Cost: $40 for 2 hours of continuing education credit towards CCM, CRC, CDMS certifications

Make $40 check payable to NC Industrial Commission Tax ID# 56-1611847

Mail completed form and check to:

NC Industrial Commission

ATTN: Medical Rehab Nurses Section

4341 Mail Service Center

Raleigh, NC 27699-4341

Phone 919-807-2616

PLEASE PRINT LEGIBLY

NAME: _____________________________________________________________________

HOME MAILING

ADDRESS:___________________________________________________________________

________________________________________________ ZIP ________________________

EMAIL (REQUIRED):__________________________________________________________

EMPLOYER: ________________________________________________________________

PHONE: ____________________________________________________________________

SUPERVISOR: _______________________________________________________________

PHONE/EMAIL: ___________________________/__________________________________

Registration Form Ncic Rehabilitation Professional Mandatory Training