Cost: $40    (includes NYS certificate for Continuing Education)

First Name	.
Middle Initial	.
Last Name	.
Birthdate	Month _____ Day _____ Year _____
Address	.
City	.
State	.
Zip	.
Daytime Phone	.
Fax Number	.
E-mail Address	.
Credit Card Type	(check one)  ___ Master Card     ___ Visa
Card Number	.
Expiration Date	Month _____ Year _____
Security Code	last 3 digits on back of card ___________
Signature	.