Infusion KNowledge, inc

facsimile transmittal sheet

to:	from:
Infusion Knowledge
company:	date:
fax number:	to send by Mail:
727-442-6874	Infusion Knowledge P.O. Box 8649 Clearwater, Florida 33758
Phone number:
1-800-337-1545
Re:
Please add me to your Mailing List

Name: ________________________________________________________________

Address: _____________________________________________________________

City: ___________________________ State: ___________ Zip: ______________

Employer: ____________________________________________________________

Department: _________________________ Title: __________________________

Home Phone (including area code): ____________________________________

Work Phone (including area code): _____________________________________

Professional Designation (i.e. RN, LPN, etc.): ____________________________

I am interested in the following programs:

Please check (P) all that apply.

___ CRNI Review ___ Current Venous Access Devices ___ I.V. Certificate Program

___ I.V. Therapy ___ Medical Errors ___ Pain Management ___ Midline-PICC

___ Presentation & Precepting Skills ___ Venipuncture ___ Other: _______________

___ I would like to receive a company information packet that details the programs
and services that are offered by Infusion Knowledge.

Additional Comments: