TELUSYS CUSTOMER SERVICE CENTER

STEP #1
MAKE YOUR SELECTIONS

STEP #2
CHECK YOUR INFORMATION

STEP #3
REVIEW / PRINT YOUR REGISTRATION

Licensure 101
View the agenda on the CDA website

Licensure 101 - 2.0 CEUs
Wednesday, February 22, 2012
6:00 - 8:30 pm
Stamford Hospital - Conference Rm A
Stamford, CT

Note: When entering your title, enter your credentials and/or job title exactly the way you'd like them to appear on your name badge.

* All items that are marked with an " * " MUST be provided. All other fields are optional.
*First Name:
*Last Name:
Title / Credentials:

Company/Organization Name:
*Address 1:
Address 2:
*City:
*State/Canadian Province:		(U.S./Canada)
International Province:
*Zip/Postal Code:		(Required for U.S.)
*Country:

*Phone:
Fax:

*E-mail Address:

Indicate your Registration Category:

	CDA Executive Committee
	CDA Member
	CDA Non-Member
	CDA Student/Intern

Make your Registration Selections:

SELECT

EVENT / OPTION NAME

Licensure 101

SELECT

EVENT / OPTION NAME

Payment Options:

Select your preferred method of payment and enter your billing contact information. If you are paying by credit card, the billing contact information should be the billing address of the card holder.

Payment information is not required for orders that total zero dollars.

Yes, my billing address is the same as the contact address above.

*First Name:

*Last Name:

Company:

*Billing Address1:

Address2:

*City:

*State *Zip Code (Required for U.S.)

*Country:

*I prefer to pay by check.

Print out your online registration confirmation and mail it with your check payable to CDA to: CDA, 68 Chase Hollow Lane, Glastonbury, CT 06033

*I prefer to pay via Credit Card.

Please Note:

You are making this purchase directly from the Telusys Customer Service Center. TELUSYS will be the only name to appear on your credit card statement for these charges if you select "Pay via Credit Card" as your payment option.

Card Type:

Card Number:

Card Security Code (Security Code Help)
(3 or 4 Digit Number)

Exp. Date:

Month Year

I understand that these charges will appear as charges from "TELUSYS" on my CREDIT CARD STATEMENT. If I am making this purchase using someone else's credit card, I will notify the card holder that a purchase was made from "TELUSYS" and these charges will appear on their CREDIT CARD STATEMENT.