PMI Printable Registration Form

REGISTRATION FORM

PROGRAM INFORMATION

COURSE NAME

ID#

Date

Time

Fee

Sign in begins 15 minutes prior to the program. Instructional materials are included. Refer to your confirmation receipt for further information.

PARTICIPANT INFORMATION

Physician/Practice Name
Speciality
Address, City, State & Zip
Phone	Fax
Email
Certified ID#	Promo Code

Participant Name	Course ID#	Date	Fee




Discounts (see below)
Total Amount Enclosed

Method of Payment
VISA MasterCard American Express Check or Money Order Payable to Practice Management Institute
If payment by credit card, please complete the following:
Card No.:	Exp. Date:	Total Amount:
Cardholder Name:	Cardholder Signature:

Donna Alwais

HOW TO REGISTER

Fax: 210-691-8972

Phone: 713-338-6787

Mail: DONNA ALWAIS, DONNA ALWAIS, 7737 SOUTHWEST FREEWAY SUITE C98, HOUSTON, TX 77074

Registration Confirmation: Confirmations will be sent to the email or fax number listed on the registration form on the day your registration is posted in our system. Please check your confirmation for accuracy.

DISCOUNTS

A 10% discount is available for all PMI-certified professionals (CMC, CMIS, CMOM, CMCO) with active credential(s). Enter active certification ID# on the registration form in the "Participant Information" section. For practice registering two or more people, or signing up for two or more programs, PMI offers the following discount structure: First registrant pays full price, second through fourth registrants paying together all receive a 10% discount. A group of five or more all receive a 15% discount.

CANCELLATION POLICY

Cancellations must be sent via email to info@pmiMD.com with "Cancellation Request" in the subject line. Correspondence must include registrant’s name, payee’s contact information, course ID number or city and date of program. PMI will issue a credit voucher for the full amount paid that may be used by anyone in the practice for a year after issuance. If cancellation notice is provided at least 7 days prior to the scheduled program, a refund may be requested, minus a 20% processing fee. Questions? Call PMI at 800-259-5562.