On-Line Registration Instructions: 1) Please fill out the ON-LINE REGISTRATION section of the registration form and click the submit button. 2) For Credit Card Payments - First click the submit button to send us your registration. Then click the PayPal button to submit your credit card information. Payment must be received prior to attendance. If you cannot attend the class, the courtesy of a phone call is expected. Cancellations made 24 hours prior to the class will be credited. No credits will be given for cancellations after the class start time or no shows. To see if a class has been cancelled due to weather or other circumstances please call 908-850-5564 ext 110 * indicates a required field. Class Registration   General :       Agency Name: * Contact Name: * Phone: * Fax: *   Classes & Dates:     Beginners select 01/05/10 01/27/10 02/10/10 03/10/10 03/30/10 04/20/10 EDI Intro select By Appt   Sys Admin I select 01/19/10 02/16/10 03/23/10 04/13/10 Sys Admin II select 01/20/10 02/17/10 03/24/10 04/14/10   Billing I select 01/12/10 02/02/10 02/23/10 03/17/10 04/06/10 04/27/10 Billing II select 01/13/10 02/03/10 02/24/10 03/18/10 04/07/10 04/28/10   Rep Writer I select 01/07/10 01/26/10 02/18/10 03/04/10 03/16/10 04/08/10 Rep Writer II select 01/21/10 02/11/10 03/25/10 04/15/10   Implement select 01/06/10 03/02/10 04/01/10 Open Forum select By Appt   Clinical select 01/28/10 02/04/10 03/03/10 03/31/10 04/22/10 Appt. Sched select 01/14/10 02/09/10 02/25/10 03/11/10 04/21/10   DMHS/USTF select By Appt Update w/s select By Appt   Student Info:     Numbers Of Attendees: One Two Three Four Five Six Seven Eight     Students Names     1. First Last     2. First Last     3. First Last     4. First Last     5. First Last     6. First Last     7. First Last     8. First Last         Payment Info.   Payments are due prior to or on the scheduled class date. An additional $50.00 finance charge will be added if these terms are not met.         Method: PayPal: Visa or Master Card AmEx - Call 908-850-5564 Check Voucher Other-Explain below     If you selected Other - Please explain.             Checks:  Make all checks Payable to MS*Health Software Corp. and mail to 128 Willow grove St. Hackettstown, NJ 07840         Credit Cards: Click the purchase button * For PayPal Purchases: use register@mshealth.com for the Recipient’s email Please Do Not e-mail credit card numbers.   If you do not receive a confirmation via e-mail within 24hrs, Please Call to confirm. 908-850-5564

MS*Health Software/CMHC

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