Personal Information
Full Name
*
First Name
Last Name
E-mail
*
School Name
*
Contact Phone Number
*
Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
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Virginia
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State
Zip Code
CEU Information
You must enter the name/date for at least one workshop. The others can be skipped if not needed.
Name of Workshop #1
*
Date of workshop #1
*
-
Year
-
Month
Day
Date
Name of Workshop #2
Date of workshop #2
-
Year
-
Month
Day
Date
Name of Workshop #3
Date of workshop #3
-
Year
-
Month
Day
Date
Name of Workshop #4
Date of workshop #4
-
Year
-
Month
Day
Date
Name of Workshop #5
Date of workshop #5
-
Year
-
Month
Day
Date
Delivery Information
How would you like to receive your certificates?
*
By MAIL at the address above
By EMAIL at the address above
Additional Notes
My Products
*
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Workshop #1 Duplicate CEU Certificate
$
20.00
Workshop #2 Duplicate CEU Certificate
$
20.00
Workshop #3 Duplicate CEU Certificate
$
20.00
Workshop #4 Duplicate CEU Certificate
$
20.00
Workshop #5 Duplicate CEU Certificate
$
20.00
Total
$
0.00
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
SUBMIT
Should be Empty: