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NHHPCO
RN/LPN Review Course Registration Form
Saturday, May 22,2010
Charlene
Forcier, RN, MS, CHPN
HPNA-Approved Instructor
8am-4pm
Registration begins at 7:30am
Catholic Medical Center, 100 McGregor Street, Manchester, NH 03102
Registration Fee: $100.00 for members of NHHPCO or
$125.00 for Non-members.
Lunch Provided
NHHPCO Individual Membership $50.00 (check here if
included)______________
Total
enclosed $___________________
Individual
Membership: $___________________
TOTAL amount enclosed:
$__________________
Form of Payment:
1 Check enclosed
1Credit card
Make checks payable to NHHPCO
Contact Information:
Name:
__________________________________________________________________________________________
Address:
_____________________________________________City:
______________________________ State: ___ Zip: _______
Affiliation (if
applicable):
______________________________________________________________________________________
Phone:
__________________________ Email Address:
________________________________________________
Credit Card
Information:
1Type:
1
MasterCard
1Visa
Card Number:
__________/__________/__________/__________ Exp. ______/_______
Total Charge Amount:
$______________________
Print name of
cardholder:
_________________________________________________________________
Authorized
Signature:
__________________________________________________________________Date:______________
Postal mail
registration is available until May 17th, 2010. Make checks
payable to NHHPCO. Mail with completed registration form to: NHHPCO,
125 Airport Road, Concord, NH 03301. An E-Mail confirmation notice
will be sent. Call 603-225-0900 or email info@nhhpco.org for questions
or concerns.
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