Registration Form

Physician      Other

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                     Last Name                        First Name                  Middle Initial
                               

Address

        City       State    Zip

  Country

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Work Phone Home Phone

Fax Number e-Mail

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Company/Hospital Affiliation
MD RN Respiratory Therapist HBO Tech Diving Tech Administrator Other

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ACHM Commercial Diver/Military Sport Scuba EMT Paramedic IBUM

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Credit Card Number (Visa or MasterCard only)
Card Expiration Date

Course Date

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Course Fee $995.00

Cancellation:

All cancellations must be made in writing. A $25 administration fee will be retained for all cancellations.

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