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Center for Professional Practice of Nursing

Center for Professional Practice of Nursing

Registration form

   

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First Name *
Last Name *
Home Address *
City *
State/Province *
Zip or Postal Code *
Work Phone * (999) 999-9999
Pager/cell (999) 999-9999
Home Phone (999) 999-9999
Please contact me during the work day by: e-mail
work phone
home phone
pager/cell
E-mail *
Employer/Department*
Cost Center
UC Davis Employee ID #
Professional License #
* Registrations are confirmed only after deposit or fee is received. All deposits must be paid separately. UC Davis employees registering from home must log in through Citrix to view employee pricing.

Note:
Special Needs:
   I need special accommodations to attend the class as specified in the Americans with Disabilities Act.
Comments:
 

Payment Method *
 Payment with a credit card online (recommended if submitting payment)
  Payment or deposit with a credit card, check or cost center by phone, fax, or mail:

Phone: (916) 734-9790
Fax: (916) 703-9903
Mail: UC Davis Center for Professional Practice of Nursing
4900 Broadway, Suite 1630, Sacramento, CA 95820


Please enter the highlighted number. This prevents automated form submission. *   

    
* Fields marked with an asterisk are required.