PLEASE PRINT OUT AND MAIL THIS FORM WITH YOUR PAYMENT:

Barkley & Associates,  POB 69901, West Hollywood, CA 90069

 

 

 

 


CD Order Form – 2008 ALL FIELDS ARE REQUIRED AND MUST BE FILLED OUT.
 

                Certification review CD package  for    FNP              

Name:  __________________________________________________________

Address:  ________________________________________________________

City/State/Zip:  ___________________________________________________

   

Email address (REQUIRED for confirmation) ____________________________

 

 

         Home Telephone #_______________ Work telephone #_____________  

State and RN License #  _______________________________
 (REQUIRED for contact hours of continuing education)
 

Place of Current Employment ______________________________________________

 

University/NP Program Attended  ___________________________________________

University/NP Program City/State  __________________________________________

 

NP Program Specialty: FNP   Date Graduated:__________________

NP Program Name of Faculty Member I worked with: ___________________________

 

Highest Degree Held (circle)   MS    MSN    DSN    PhD   DNSc    Other: _________

 

How did you hear about Barkley & Associates? _______________________________

 

Were you recommended to take a Barkley & Associates Course from your NP Program Director/Coordinator?    YES/NO

 

Order Fee (check/MO payable to Barkley & Associates):

CDs WITH handouts and 22.5 CEUs

$389.50 + $10.00 Shipping = $399.50
ALL FIELDS ARE REQUIRED AND MUST BE FILLED OUT.
 

- Total Enclosed…………………$399.50  

Thank You!

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