Continued Education Credits Registration Form

Pennsylvania Self Insurers’ Association A to Z
Workers’ Compensation Administrative & Management Training Course

March 11-12, 2010 – Sheraton Harrisburg/Hershey

To obtain Continued Education Credits, complete this form and mail or fax along with payment payable to Preferred Systems, Inc. to the address below.

Preferred Systems, Inc.
1341 West 6th Street
Erie, PA 16505
Phone: (888) 455 – 7437 Fax: (814) 455 – 7026


Name: _____________________________________

SSN# / License Number: ________________________

Company: ___________________________________________________________

Street Address: _______________________________________________________

City: ______________________________ State: ______________ Zip: ________________

Business Phone: _____________________ Fax: ___________________

E-mail: ___________________________________________________

Registrants Signature: __________________________________________

Payment Method

Check, Number __________________

Credit Card Type: � Visa �Mater Card         

• Account Number: _________________________________
  
  
• Expiration Date: _______________

Payment must be received before continuing education credits will be processed

Please check Type of Credits Needed
� Attorney ($100.00)
� Insurance ($100.00)
� Financial Examiners ($100.00)
� Insurance Regulatory
�Examiners ($100.00)
� Board of Certified Safety Professionals ($50.00)
� Accountant ($70.00)
� American Board of Industrial Hygiene ($50.00)
� PA Board of Nursing ($70.00)
� CDMS ($70.00)
� CRCC ($70.0)
� CCMC $70.00)
� Certified Workers Compensation Professional ($100.00)
� Human Resources Certification Institute ($100.00)

� Other (specify) _________________________________________