REGISTRATION FORM

All credit card transactions will be processed as USF Health Professions Conferencing Corporation.
Any questions regarding registration and/or payment should be address to the Office of Continuing Professional Development at (813) 974-4296 or sdodge@health.usf.edu.
All personal information is sent using a secure connection using 128-bit encryption. For more information about the site certificate, please click HERE.

Health Care Risk Management State Licensure Program
Registration Form
First Name
Last Name
Address
City
State
Zip
Country
DeFault Password
Title
(If Other)
Gender
Male Female
Specialty
License #
Organization
Birthdate
Month Day
E-mail *

Phone
Fax
*Email address is required for participation in this course.
Course Fees
 
$799 Regular Fee

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Payment Method

Credit Card
Mastercard
Visa
American Express
Name (exactly as on card)
Credit Card Number
Expiration Date (mm/yy)


Check
Please make checks payable to:
USF HPCC
University of South Florida
Continuing Professional Development
Attn: NG2004625/1170
P.O. Box 864240
Orlando, FL 32886-4240

 

Refunds:
A cancellation fee of $200 goes into effect one week from the original registration date if no materials are downloaded and if you have not participated in any chat sessions. No refunds will be made after this time period.
About SSL Certificates

 
Accommodations for Disabilities: Please notify the CPD Office, 12901 Bruce B. Downs Blvd., MDC Box 60, Tampa, Florida, 33612 or call (813) 974-4296 a minimum of ten working days in advance of the event if a reasonable accommodation for a disability is needed.

Events, activities and facilities of the University of South Florida are available without regard to race, color, sex, national origin, disability, age, or Vietnam veteran status as provided by law and in accordance with the University's respect for personal dignity.