Super CE Registration Form

Super Saturday CE For Educators
Registration Form
October 18, 2008 and/or February 28, 2009

Print the form below. Type or print all information and mail appropriate fees and the registration form to address below.

NAME ________________________________

_________________________________
STREET ADDRESS CITY STATE ZIP CODE

____________________________________________
AREA CODE DAYTIME PHONE NUMBER

*___________________________________
EMAIL ADDRESS

Credentials and Degree:

Confirmations will be sent only to email addresses

For those employed in private practice offices, please supply the following:

OFFICE NAME_____________________________________________

_________________________________
STREET ADDRESS CITY STATE ZIP CODE

_________________________________________________
AREA CODE DAYTIME PHONE NUMBER

Check the Super CE Saturday you wish to attend:
____ October 18, 2008 Zane State College, Zanesville
Postmark Deadline: October 8, 2008
____ February 28, 2009 Raymond Walters College, Cincinnati
Postmark Deadline: February 20, 2009

Check one:
____ Pre-registered OSRT Member: $95
____ Pre-registered Non-member: $155*
*(includes OSRT membership application)
____ Onsite Registration add $20

Must be post marked prior to deadline date or register at the door with $20 late fee. Lunch not guaranteed for late registrations. Cancellation Fee: $25.00

Make check or money order payable to OSRT
Credit card payments welcome:

Credit Card:
(check type):

Visa:

Master Card:

Account number:

Expiration Date:

Amt Charged $

Name on Card:

Signature:

Be sure to mail payment and registration form (and OSRT application form if applicable) by the postmark date to:

Emilee Burger, BS, RT (R) (CT)
OSRT CPE Committee Co-chair
545 Raccoon Ln Rd.
Sunbury, Ohio 43074
Email: osuemma@hotmail.com
614-566-5734 ext 3

CE events are subject to cancellation if unforeseen situations arise or if the number of pre-registered attendees is less than10. A full refund would be given in the event of cancellation.