* Name:
* Business:
* Address Line 1:
   Address Line 2:
* City:
* Zip/Postal Code:
* Phone:
* Email:

I will be applying for continuing education from:
(Credit hours will be announced the week of October 30)

* Continuing education ID numbers are required for each certification you select.

(Per CE regulations, Insurance agents must attend entire program to receive credit.)

I plan on attending the afternoon session on:

* 1:00 - 2:00 pm

* 2:15 - 3:15 pm

* 3:30 - 4:30 pm

Services for Physically Challenged Individuals:

Atrium Medical Center Foundation wishes to take reasonable steps to ensure no individual who is physically challenged is discriminated against because of the absence of the auxiliary aids and services. If special arrangements are needed, please contact us at Foundation@AtriumMedCenter.org or (513) 420-5144.