PAY BY CHECK OR MONEY ORDER: Make check or money order payable to: Education Workers Group PRINT THIS FORM and mail along with payment to: Education Workers Group 499 Ernston Road Suite A10 Parlin, NJ 08859 NAME: (As you want it displayed on your certificate) -------------------------------------------------------------------------------- First Name __________________________________________ (required) Last Name __________________________________________ (required) Middle Name __________________________________________ ADDRESS: (As you want it displayed on your certificate) -------------------------------------------------------------------------------- Address __________________________________________ (required) Address (line 2) __________________________________________ City __________________________________________ (required) State __________________________________________ (required) Country __________________________________________ (required) Zip/Postal code __________________________________________ (required) CONTACT INFORMATION: -------------------------------------------------------------------------------- Phone __________________________________________ (required) E-Mail __________________________________________ (required) LOGIN INFORMATION: -------------------------------------------------------------------------------- Choose a unique username and password that you will use to login to the web site. Username __________________________________________ (required) Password __________________________________________ (required) PROFESSION: -------------------------------------------------------------------------------- --- Circle Your Profession below --- Chiropractor - Dental Hygienist - Dentist or Optometrist - Physician - Podiatrist - Psychologist - Registered Nurse - Teacher - Social Worker - Mental Health Counselor - Marriage and Family Therapist - Creative Arts Therapist - Psychoanalyst - Other CHOOSE YOUR WORKSHOP(S): -------------------------------------------------------------------------------- Check the workshop(s) you would like to take and calculate the total at the bottom: ______ $39.95 - Child Abuse Prevention Workshop ______ $44.95 - School Violence Prevention & Intervention Workshop ______ $39.95 - Infection Control Workshop ______ $74.95 - Both Child Abuse Prevention & School Violence Prevention Workshops $ __________ TOTAL Make check or money order payable to: Education Workers Group Mail this form and payment to: Education Workers Group 499 Ernston Road Suite A10 Parlin, NJ 08859 *** Please allow 2-5 business days for your workshop(s) to be active. If you are sending a personal check, please allow 5-7 business days for your workshop(s) to be active. Once your workshop(s) are ready you will be contacted via email. If you have any further questions please contact us at (718) 701-0385