AO ASIF Nursing Continuing Education
A Basic and Advanced Course for Operating Room Personnel

Please do not consider yourself registered in this Course until written confirmation is received.

Course Name:

Please indicate which Course you would like to attend:

Basic Course
Advanced Course

Attendance may not be split between Courses. Advanced Course attendees must have completed a previous Basic Course.

Basic Course attended:
Date:
Location:

Enclosed is my check payable to:
AO ASIF CONTINUING EDUCATION

Please charge my credit card:

Master Card VISA Exp. Date: Card Number:
Signature (Signature of card holder required, if faxing or mailing form):

Printed Name of Cardholder:

Name (as it should appear on your certificate):


Credentials (i.e., RN, CST, etc.):


Social Security No. (used identification purposes only):


Home address:

City:

State:

Zip:

Home Phone:

Office Phone:

Office Fax:

Name and City of Hospital:


AO ASIF Consultant:

• Registration is required in advance and is not accepted unless accompanied by appropriate fees. Phone-in registrations not accepted.
• Please do not consider yourself registered for this course until written confirmation is received.
• Registration deadline: December 5, 2003. Refunds will be issued if written cancellation is received by this date.

Do you have any special needs:

If you are registering and paying by check, please print and mail this registration form with payment to:

AO ASIF Nursing Continuing Education
RE: Lancaster ORP Course
1301 Goshen Parkway
West Chester, PA 19380
Tel (800) 535-2369 (press 5)
Fax (610) 719-6532

Please do not consider yourself registered for this course until written confirmation is received.

Please press this button to submit your
registration form online using your credit card:

Thank you.