ExamPrepRegistration

TITLE: (Ex. Dr/Ms/Mr/Mrs/Miss)

Last Name: First Name: Middle Initial:

Company/Organization:

HomeAddress:

Home City:

Home State: Home Zip Code:

Primary Email: Secondary Email:

Phone: Cell:

Are you a NYMHCA Member? Membership number:

Membership Type: (Professional/Student/Retired/Associate)

If you are NOT a NYMHCA member, would you like membership material mailed to you?

Work Setting:

Areas of Specialization:

You can only register for a workshop if you have contacted a presenter and have received a commitment from the presenter and a date(s) of the training. No presenter listed on this website can offer a workshop that is not sponsored by NYMHCA.

Date(s) of Workshop:

Workshop Presenter:

Location of Workshop:

There are 3 easy ways to register:

1.Email this to NYMHCA by clicking on the submit button at the bottom of this page.

2.Print off the printable form (click on button above) and fax it with credit card info to: 631- 472-3866

3.Print off printable form and mail with your check to: NYMHCA, 206 Greenbelt Parkway, Holbrook,

New York 11741-4411

*If you choose to process your credit card payment yourself please click on the button below. You will be directed to ProfessionalCharges.com. NYMHCA uses the secure payment processing services of ProfessionalCharges.com to handle online credit and debit transactions. This payment will appear on your credit card statement as "ProfessionalCharges.com."

*If you process your credit card payment yourself, please then use your "BACK" button to return to this page, and click the SUBMIT button at the bottom so we receive your registration information.

If you prefer that we process your credit card payment please provide us with the following information:

Method of Payment: (made payable to: NYMHCA)

Credit Card Type:

Name on Card:

Credit Card Number:

Credit Card CVV#: This is the 3-digit number on the reverse of your credit card. We cannot process your payment without it.

Expiration Date:

Questions? Please call (631) 472-3866 or 1-800-4-NYMHCA

Mail registration form to:

NYMHCA

206 Greenbelt Parkway

Holbrook, NY 11741

Refund and Cancellation Policy :

NYMHCA will refund 80% of the total registration fee for cancellations received in writing no later than two weeks before the date of the workshop.

If there is insufficient enrollment for a large group workshop, and the presenter cannot do the workshop with a smaller group, NYMHCA will make every effort to find another presenter willing to the training. In the event that is not possible, your entire registration fee will be refunded.

*You must register for a workshop at least 24 hours before it begins. Anyone who attempts to register less than 24 hours before a workshop will not be on the presenter's registrant list and will NOT be admitted!

To ensure your admittance to a workshop, we suggest that you bring with you a copy of the email confirmation of your regsitration that you received from our office.