REGISTRATION FORM
Thank you for your interest in the ADAVANCED CHARTERED BENEFIT CONSULTANT (ACBC) course and, more specifically, your interest in furthering your knowledge and expertise in Consumer-Driven Health Plans. Please complete the following information and return to us with payment or payment arrangements AT LEAST SEVEN (7) DAYS BEFORE THE CLASS. If you do so, the total tuition is $200. PAYMENTS RECEIVED AFTER THAT DATE WILL REVERT TO THE NORMAL TUITION LEVEL OF $250. THIS COURSE IS VALUED AT 8 CE CREDITS IN MOST STATES (9 IN NY).
Name: ___________________________________________ (as you want it to appear on your certificate)
Address: _______________________________________________
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Phone: _______________________________ Fax: _____________________________________
Email Address: _____________________________________________________
The format of these classes is via web seminar consisting of FOUR HOURS PER DAY FOR TWO CONSEQUTIVE DAYS (1 pm until 5 pm central time unless otherwise advised)
ACBC Class Dates for 2008
Class # 1 _n/a _ Feb 14th & 15th Class # 3 _____ July 17th & 18th
Class # 2 _n/a _ May 15th & 16th Class # 4 _____ Oct 16th & 17th
IMPORTANT: Because there is continuity between day one and day two of the class, you will be required to participate in both days’ sessions. You will not be able to take day one of one class and day two of another.
Select the class you would like to participate in
Your CBC listing and your NAABC membership will be extended for TWO YEARS from the date of class completion or for TWO YEARS from the date of current term’s expiration, whichever later.
PAYMENT OPTIONS
Payment option 1: _____ Check or Money Order PLEASE NOTE: IF MAILING A CHECK OR MONEY ORDER, PLEASE ALSO FAX THIS FORM TO 630-858-2130 AT LEAST SEVEN DAYS BEFORE THE CLASS.
Payment option 2: _____ Credit Card
___________________________________________
(signature)
If Payment Option # 2 is selected, please complete the following:
Please circle card type: AMEX Visa MasterCard
Card # ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Expiration date ___ ___ / ___ ___
Payment Amount: _________________
Signature ______________________________________
Date________________ Printed Name as it appears on Card _______________________________________
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You may either mail the completed form to the address below or fax to 630-858-2130
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THE REGISTRATION MATERIALS NEED TO BE IN THE NAABC OFFICE AT LEAST SEVEN DAYS BEFORE THE CLASS DATE TO ASSURE THE DISCOUNTED TUITION RATE (normal tuition is $250)UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
THANK YOU FOR YOUR PARTICIPATION AND FOR YOUR INTEREST IN THE EDUCATION THIS CLASS WILL PROVIDE!
The National Association of
Alternative Benefit Consultants
435 Pennsylvania Avenue, Glen Ellyn, IL 60137-4401
Toll Free: 800-627-0552 Fax: 630-858-2130 Email: NAABCX@aol.com