Lord Jim --- I'm Him, April 26

Lord Jim - I'm Him

Gavriel Reisner, PhD, LP

Sunday, April 26
5pm - 7pm,
Live online - Zoom

The Zoom link will be emailed on

Friday, April 24th, between

1pm and 2pm

Fill out the form to register to our event. Please remember to REVIEW your information before you press SUBMIT. You will receive an official confirmation from NPAP Database after you press SUBMIT.

Event code

Enter your first and last name as you wish it to appear on your certificate.

Name*

First NameLast Name

E-mail*

Confirmation Emailexample@example.com

Phone Number

Format: (000) 000-0000.

In-person attendanceRemote/Zoom attendance

NPAP MembersOther ProfessionalsCandidates/Students

Candidate/Student of which institute?*

CE contact hours will be granted to participants with documented attendance and completed evaluation form. It is the responsibility of the participants seeking CE hours to comply with these requirements. Upon completion, a Certificate of Attendance will be emailed to all participants. Please enter your license number and credential if you want CE hours.

Enter your license number as you wish it to appear on your certificate.
Enter license number AFTER the apostophe. Please do not erase the leading apostophe required to preserve the formatting.
Remember to INCLUDE ALL CHARACTERS in your license number, INCLUDING ZEROS.

YesNo

License Number

Remember to include all characters in your license number, including zeros.

Formatted LicNum

KEEP HIDDEN: (DB timerloop needs this. Also depends on proper condition setting)

Credential

LMSW, LCSW, LMFT, LP (Licensed Psychoanalyst), PhD (Psychologist)

Event Selection and Payment

Please pay by selecting the correct category. A contribution is appreciated, but it does not replace the original fee for the program. Thank you for your cooperation.

Event Payment*

NPAP Members

$25.00

Other Professionals

$40.00

Candidates/Students

$15.00

Contributions Help Us Grow

To give, click on contribution and specify amount in the box below.

$1.00 Suggested amount, $10 - $20
Item subtotal:$0.00

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

Review your information by pressing REVIEW REGISTRATION. If all information is correct, then press SUBMIT on the next page. Press the BACK button to correct any erros in the registration form.