Annual Education Provider Registration Form

Annual Education Provider Registration Form

This form should be completed once per calendar year by each continuing education course provider. Please complete this registration form prior to submitting any course applications.
Education Provider/Company *
Company Main Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Company Website
Main Contact Person *

First Name Last Name
Main Contact Title *
Main Contact Phone *

Area Code Phone Number
Main Contact Email *
example@example.com
Agreement
Please visit this page to read the Course Approval Requirements and Guidelines Document. By registering to be an IHS Education Provider, I understand that IHS reserve the right to withdraw approved provider status at any time for failure to abide by these requirements.
Check each box to confirm agreement. *

Thoroughly read all education provider information. Abide by the Course Approval Requirements and Guidelines document. Agree to fees and payment policies.
Annual Registration Fee
The Annual Registration Fee is due every year (and is based on the calendar year) prior to your first course application. Payment of this fee must be submitted with the annual registration form.

Education Provider Annual Fee: $400 USD

IHS Chapter Annual Fee: $250 USD

To expedite processing the registration form, please provide a credit card to pay the annual fee. Once the registration is accepted, the credit card will be charged. IHS will send you an email with a receipt and your company's Education Provider Number.

Annual Provider Registration Fee

$ 400.00

IHS Chapter Annual Registration Fee For IHS Chapters only

$ 250.00

Total

$ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Payment Method

Visa Mastercard Discover American Express
Name on Card

First Name Last Name
Card Number
Expiration Date
Security Code
If you are unable to pay by credit card, an invoice will be emailed to you. Please note, courses will not be approved until payment for the annual registration fee is received. For questions regarding IHS course approval, email education@ihsinfo.org.
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Annual Education Provider Registration Form

Agreement

Annual Registration Fee