OccuCom^® Ergonomic Certification
Seminar Registration Form

To Register: complete this form and fax or mail to:

OccuCom^®
1325 Howard Avenue #903
Burlingame, California 94010

Phone Number: (866) 326-1146
Fax Number: (650) 344-0138

Select One:

November 21, 22, &23

Please indicate the manner you would like your name and professional designation/degree to appear on your certification and security badge:

Name:                                                                                                        

Professional Designation/Degree:_______________________________       

Facility Name (if applicable):                                                                   

Mailing Address: Home (  )  or Work (  )_________________________        

City:                                                          State:             Zip:                    

Email Address:                                                          

Credential Fees:
      $695 prior to November 4, 2003
      $795 on or after November 4, 2003

Licensee Fees:
      $2,750 prior to November 4, 2003
      $3,150 on or after Nov. 4, 2003

Select Payment Type: (Please make checks payable to: California Health Consultants)

     Enclosed is my check for $____________

   Please bill my:     Visa      MasterCard

Account #                                                    Expiration date:                   

Signature