PLEASE SELECT SEMINAR:

____ September 10, 2012 Accreditation Seminar, Cambridge, MA

____ November 26, 2012  Accreditation Seminar, Las Vegas, NV 

AGENCY INFORMATION:

Company________________________________________________________________

Address_________________________________________________________________

City______________________________    State________   Zip____________________

Country_________________________________________________________________

Phone ( )____________________ Fax ( )____________________

Company Website ________________________________________________________

Agency Provider Type:

 ___County  ___Fire Department  ___Hospital  ___Municipal   ___Police  ___Commercial
___Third Service ___Public Utility Model ___ Other (explain)______________________

Total # of medical transports per year: ___________________

Please check one:

____ We are seeking accreditation in 2012.
____ We are seeking accreditation in 2013.
____ We are seeking accreditation in 2014.
____ We are a re-accrediting agency.

SEMINAR ATTENDEES: 

1.Name:_____________________________ Position/Title:_______________________

Email:_______________________________ Cell/Mobile: ________________________

2.Name:_____________________________ Position/Title:_______________________

Email:_______________________________ Cell/Mobile: ________________________

3.Name:_____________________________ Position/Title:_______________________

Email:_______________________________ Cell/Mobile: ________________________

4.Name:_____________________________ Position/Title:_______________________

Email:_______________________________ Cell/Mobile: ________________________

Email required for seminar registration confirmation and distribution of materials.

REGISTRATION FEES:

____  Single Registration:  1 x $425.00 (USD) =  $425.00 

____  Multiple Registration Discount: _____ (#attendees) x $375.00 (USD) = _____ Total Due

*To qualify for the discounted rate, registrations must be submitted together and paid on the same check.

METHOD OF PAYMENT:

____ Check (Payable to CAAS)
____ American Express
____ Visa
____ Mastercard

Card Number_____________________________ Expiration Date_________ Security Code______

Signature________________________________ Name on Card___________________________

Cancellation Policy: If it is necessary to cancel the registration, (1) an alternate attendee may be named by the agency with no penalty or (2) the registration fee will be credited to a future CAAS Accreditation Seminar. CAAS must be notified of your change prior to the seminar date.  There are no refunds or credits for no shows.

Return completed registration form to:

If you have any questions, please call (847) 657-6828 or e-mail: marciem@tcag.com.

__ Check here if you require special accommodations in order to attend this meeting, and a CAAS staff member will contact you.