* Name
as you would like it to appear on the Certificate, including "RN", "MD", "CST" etc.
    (additional students will be listed in a field lower down on this form)
Title/Dept
Company/Hospital
* Mailing Address
Where Certificate
will be mailed.
Home Address
Work Address
* Registratnts Email
Confirmation, and any course materials and online authorizations will be sent electronically via email to this address, in addition to any course status updates.
Watch for emails from "Mindflash" in your Spam folder.
* Confirm Email
* Phone
* Online Course
If you select the 2+ persons option, enter names & emails in the box below. You can also just call us later with the names & emails. If you buy the one person program, you have 30 Days to add the second person for the discounted price.
Name & "CORRECT" Emails of Additional Students
Additional Students for the Programs:  Please list their names as they should appear on Certificates, and a unique email to set them up. You can also call our office to add later. Make sure the email address is CORRECT. Up to 5 total additional are included in the "2+" Course Selections. An additional fee of $125 pp will apply past the initial 2 persons. You can add these people at any time in the future - no time limit.
Remarks? or
Requests?
* Payment Method:
*Enter either Purchase Order # or Credit Card Info
No payment information is required for the "FREE PREVIEWS"
Purchase Order #
Student will have access to the online program after payment has been received for the Purchase Order. Otherwise please us a CC for quicker access.
Credit Card
CardHolder Name:
Card Number:
Expiration Date
3 Digit Security Code on back:
By placing this order and clicking the SUBMIT button below, you acknowledge that you have read the REFUND POLICY and agree with its terms.

Privacy Policy
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Please type the txt into the box
If I am paying by credit card, I hereby authorize charges to my card for the item(s) ordered
You'll the have access to the program in 24 hours or less after your order has been processed.
mm/yy
Must include Area Code & Phone # for U.S. #'s
Use Format 5554441212 - No Hypens, Spaces or Dots
 
PROFESSIONAL MEDICAL EDUCATION ASSOCIATION, INC.
USE THIS PAGE TO ELECTRONICALLY REGISTER FOR ONLINE COURSES.
Credit Card Payments accepted below. Checks are made to Professional Medical Education Assn, and mailed to:  PO Box 997, Grove City, OH 43123.
You may also Print Out and Complete this form, then mail to the address above or fax to 305-946-0232
                      
Electronic Registration form - all Home-Study/Online Courses
(use the separate form for in-person seminars)

Once you have registered you will receive an email confirmation and directions within about 24 hours. Payment must be received prior to starting course.
You'll set up your own password online with the email address you provided below.
Course Manual and Slide Handouts are available as a download from the first slide in the first module of the course. Don't forget to download them.
* Indicates required information: