CAAS Accreditation Online, On-Demand Webinar Series

AGENCY INFORMATION:

Company________________________________________________________________

Address_________________________________________________________________

City______________________________    State________   Zip____________________

Country_________________________________________________________________

Phone ( )____________________ Fax ( )____________________

Company Website ________________________________________________________

Agency Provider Type:

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

Total # of medical transports per year: ___________________

Please check one:

____ We are seeking accreditation in 2010.
____ We are seeking accreditation in 2011.
____ We are seeking accreditation in 2012.
____ We are a re-accrediting agency.

WEBINAR SERIES ATTENDEE: 

1.Name:_____________________________ Position/Title:_______________________

Email:_______________________________

Email required for seminar registration confirmation and distribution of materials.

REGISTRATION FEES:

 Registration: _____ (Number of attendees) x $225.00 (USD) = _______ Total Due

METHOD OF PAYMENT:

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

Card Number_____________________________ Expiration Date____________________

Signature________________________________ Name on Card_____________________

Return completed registration form to:

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