2015 CCEMTP(SM) CONTINUING EDUCATION REGISTRATION FOR CURRENTLY CCEMTP(SM) CERTIFIED Registration Fee: $100.00 per day PLEASE SELECT PREFERRED COURSE DATE(S) – LIMIT Monday, July 13, 2015 Tuesday, July 14, 2015 Wednesday, July 15, 2015 Friday, July 17, 2015 Saturday, July 18, 2015 FIVE (5) DAYS Monday, July 20, 2015 Tuesday, July 21, 2015 Thursday, July 23, 2015 Friday, July 24, 2015 Continuing Education Credit This continuing education activity is approved by UMBC, an organization accredited by the Continuing Education Coordinating Board of Emergency Medical Services (CECBEMS). Please type or print clearly. A confirmation packet will be sent upon receipt of registration and payment. Mail this completed form and your check made payable to "UMBC" to: University of Maryland, Baltimore County Dept. of EHS/PACE 1000 Hilltop Circle, Sherman Hall, Room 316 Baltimore, Maryland 21250 OR fax your registration form with credit card information to (410) 455-6713. Name: Email: Address: City, Sate, Zip: Phone: NREMT-P/Paramedic Lic #: RN, MD License #: Student #: Alternate Phone: Exp. Date & State: Exp. Date & State: # of Days Continuing Education Daily Fee $ 100.00 Enclosed is my check in the amount of >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Please charge my VISA MasterCard (please circle one) >>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Credit Card Convenience processing fee (add to balance above) TOTAL AMOUNT TO BE CHARGED>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Card Number: Address if different from above: V-code: Enter Amount $ 5.00 Expiration Date: (last three digits on back of card) Name as it appears on Card: Signature: Cancellations/Refunds subject to a $45.00 withdrawal fee. After the withdrawal deadline all tuition will be forfeited. refunded or transferred to another course date at UMBC's expense. For Office Use Only T-Code: 410 Fund Code: 1113 Prog Fin: 000 Department: 10556 Account: 4873372 Project: CV390043 Actv ID: CNV Resc Type: OPREV Revised 6/15