2010 Pennsylvania Bureau of Workers' Compensation Annual Conference
June 7-8, 2010

Hershey Lodge and Convention Center

Continued Education Registration Form

• The Pennsylvania Department of Insurance approves this program for 12 hours of continued education credits
• This course has been submitted to the American Board of Industrial Hygiene for 1.67 Safety CM Points
• The Board of Safety Professionals (CSP's) has approved this program for 1 COC Points
• Certified Workers' Compensation Professionals may earn 12 hours toward recertfiication as a (WCCP) by the Certified
  Workers' Compensation Compensation Professional Center of Michigan State University.
• This program has been approved for 10 recertification credit hours toward PHR and SPHR through the Human
  Resource Institute (HRCI). For more information about certification or recertification, please visit the HRCI homepage
  at http://www.hrci.org/
• The Society of Financial Examiners has approved this program for 12 Continuing Education Hours
• The Insurance Regulatory Examiners Society has approved this program for 12 Continuing Education Hours
• This Worker Compensation Conference qualifies for 10 Continued Education credit hours for Certified hazard Control
  Management (CHCM), Certified Healthcare Safety Professionals (CHSP) and Certified Product Safety Management
  (CPSM)

Type of Continued Education Credits Requested

PA Insurance ($160.00)	Certified Workers Compensation Professional ($160..00)
Human Resources Certification Institute (PHR/SPHR) ($175.00)	Board of Safety Professionals (CSP'S) ($100.00)
American Board of Industrial Hygiene ($100.00)	Insurance Regulatory Examiners ($160.00)
Financial Examiners ($150.00)	Certified Hazard Control Management ($100.00)
Certified Product Safety Management ($100.00)	Certified Healthcare Safety Professional ($100.00)

Name: ________________________________________ License # if Applicable ___________________________

Company _____________________________________ Street Address: ______________________________________

City: ____________________________________ State : _________________ Zip: _____________

Phone: _________________________ Fax: _______________________ E-mail: _______________________

Payment Method:
1.Check # ____________________________ for $ ________________________ is enclosed

Charge My Visa Mastercard Card# __________ __________ __________ __________ Exp. Date ________________

Authorized Signature: _______________________________________________________

To receive continued education credits please print and fill out then fax or mail the registration form along with payment to

Preferred Systems, Inc. 1341 West 6th Street, Erie, PA 16505
Ph: 814 456 - 0406 / Fax: 814 455 - 7026 / Toll Free: 888 - 455 - 7437

one registration per form, may duplicate as necessary