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    PMHNP     

          

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 : PMHNP - Graduation Date: _______________________________

 

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 12.5 CEUs

$299.50 + $10.00 Shipping = $309.50
ALL FIELDS ARE REQUIRED AND MUST BE FILLED OUT.
 

- Total Enclosed…………………$309.50  

Thank You!

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