Nijenhuis Two Day Program Registration

 

Name:  __________________________________________________ 

Phone:  _____________________ email: ________________________

Address: _________________________________________________

________________________________________________________

 

Please check all that apply:

 

____ NESTTD Member: $210               

____ NESTTD Student Member: $180

____ NESTTD Full-time Non-profit Agency Employee Member: $190

____ Non-member: $250

____ Non-Member Full-time Non-profit Agency Employee: $230

____ Non-member student or retiree: $230                                         

____ 12 CME’s (for M.D.’s only): $20

 

TOTAL Enclosed $_______________

 

Please make checks payable to: NESTTD

Send  to: PO Box 506, Malden, MA 02148-7837

 

Please include a $20 Late Charge for all registrations postmarked after 3/2/2007.