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We now take Credit Cards!

User Note: Use this Credit Card Form separate and independent of the below “Register Now” Form.

NCEHSOP CE Training Course Registration
Course Title
Name
First Last
Email*
Enter Email Confirm Email
REHS Number (Note if registering from out-of-state, please use 5000.)*
Please enter a value between 100 and 5000.
NC County Health Depts & Districts (If retired, unaffliated or other employment, denote as NA and go to the next box.)
Other
Supervisor's Name
Phone Number
Emergency Contact Information
Name
Relationship
Address
Phone
Comments. Use for special considerations, such as Accessibility.
Comments. Use for special considerations, such as Accessibility.
Disclaimer, terms and agreement.
Registration does not guarantee the participant a space in this course, but puts the participant on an active wait list.
Once payment is received in-full, the participant will be awarded a space in the course if seats are remaining.

All information must be completed and returned to
NCEHSOP
PO Box 316
Wentworth, NC 27375
with payment of check or money order made out to NCEHSOP for the total of (please write down and enclose the appropriate amount): $_________
**MUST BE POSTMARKED AT LEAST 7 CALENDAR DAYS FROM THE FIRST DAY OF THE COURSE IN ORDER TO BE REGISTERED.**
I have read and understand the disclaimer, terms and agreement above.*
- I agree
Name
This field is for validation purposes and should be left unchanged.

North Carolina Environmental Health State of Practice Committee