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:
Class Registration

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.): ____________________________

What class are you registering for? ____________________________________

Date(s): _______________________ Location: _______________________________

Amount: $_____________________

Method of Payment:

q Check or Money Order (made payable to Infusion Knowledge)

q Visa q MasterCard q Discover

Credit Card Number: ______________________________ Expiration Date: _________

Name as it appears on Card (if different than above): ______________________________

Address that Credit Card is Billed To (if different than above):

___________________________________________________________________________

Authorized Signature: _____________________________________________________________

A letter of confirmation will be sent to you within 7 days of receipt of your Registration Form.

Cancellation Policy:

Infusion Knowledge must receive all cancellations in writing no later than 7 days prior to the course date; or a $50 processing fee will apply. We reserve the right to cancel any program if sufficient registrations are not received.

Additional Comments:

Infusion Knowledge - Po box 8649- Clearwater, FL 33756