ISSTD Professional Training Fax/Mail Registration Form

Please read all of these instructions before downloading this page: This form is for persons who have contacted their local seminar faculty and have already been accepted in the Professional Training Course. ISSTD has been notified of your acceptance and you have been given a registration number. Your registration is complete when you fax this form with a copy of your current valid license for clinical practice in your local jurisdiction (or, if in training, a letter of recommendation from the chairperson of your training program/department) to the fax number at the bottom of this page, and payment is approved by your credit card company. You wil be notified of a completed registration via email (preferred), or fax, as soon as possible. Please help us keep our administrative costs down by including your email address. We do not sell addresses. This is for use in this course only.
Fees: Current info http://www.isst-d.org/training/Training-index.htm#fees CE/CME credits available only in U.S. and Canada). This fee includes all aplicable copyright fees and the course materials. ALL FEES ARE IN U.S. DOLLARS. If you withdraw from the course less than 15 days priro to its local starting date, there is a $25 non-refundable charge. Registration is limited to 12 participants per face-to-face location. Once the course starts no new students can be accepted. The course fee is not refundable if you withdraw from the course after two weeks prior to its start, unless an acceptable replacement for your registration is found, in a timely fashion, prior to the start of the course. Refund of fees, and acceptance at that time, is the decision of the course Directors. All materials used for this course are subject to copyright laws and are not for duplication or distribution by course participants. Sharing materials from this course is a violation of copyright law and ISSTD rules. Please download this form by simply pressing the <Print> button on your browser. Please fill in all fields of this form. Information provided is only for this course and will not be sold, or otherwise distributed or used in any other fashion.

Name:(last): (first): (initial):

Address: (street)

City State Zip _______+_____

Credentials LCSW PhD MD Other_______ License#____________ Jurisdiction:

Office Telephone:	Home Telephone:
Fax Number:	Email address:

ISSTD Member___ Non-Member___ CE/CMEs (add $40) ___	Course I am attending: Child & Adol___ Intro___ Standard ___ Advanced___ Master's____
Credit Card (circle one) Visa MC AMEX Discover Card No:	Total fee (USD) $________ Expiration date ____/____
Signature (read below before signing)

Faxing this form to ISSTD, with your signature, signifies acceptance of the terms and conditions for this course offering, noted above, and that you are a licensed clinician with a current valid license to practice your specialty in the jurisdiction indicated.

Please print and fax this form to ISSTD Headquarters: 703-610-0234, or mail this form to:

ISSTD Headquarters
8400 Westpark Drive
Second Floor
McLean, VA 22102

My check (in USD from US bank) is enclosed for: $__________ Make checks payable to “ISSTD"