Online Application for Certification Exam

Simple Steps to Complete

Application

1. Enter General Information

2. Click on the "submit button"

4. Proceed to Checkout

5. Select your Perfered Method of Payment

3. Select Exam Date

Space cannot and will not be held until registration is complete and payment is received. Taping of any Seminar or course is strictly prohibit by any means, all seminars and courses are subject to the acceptance of our terms and condition without any modification. Copavin reserves the right to make anuy change necessary. for any and all questiones you may have please do not hesitate to call us at once.

For further assistance here is our Business Card

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ONLINE REGISTRATION

FOR CERTIFICATION

Americans with Disability Act

Click here to Submit Registration Application

Contact Information

Professional Title:

First Name:

Terms and Condition

Please check the box below to confirm you have read the terms and conditions for the course, certification exam, and/or manual you desire. Click here to view a new window with the "Terms and Conditions Page"

Education Information

All of our courses/testing examinations intend to fully comply with the ADA. If you need any special assistance please check the box below and indicate the best phone number for an event staff coordinator to contact you. To ensure proper accommodations are made please ensure requests are in 3 weeks prior to event.

Last Name:

Address:

City:

State/Country:

Zip Code:

Contact Phone:

Cell Phone:

Fax Number:

Email:

Alternate Phone:

Work Information

Work Place:

Position:

Address:

City:

State/Country:

Zip Code:

Hospital Privileges

List can be separated using commas or by pressing enter

Member of Professional Associations:

List can be separated using commas or by pressing enter

Medical Degree:

Number of Years in Practice:

University of

Year of Graduation :

Country/State Location of License:

Phone:

Ext:

Certification Step

Please Select Option(s)

Cost Per Person To Receive Seminar

Next step submit aplication and make payment

Next step, is to submit your aplicacion and make your payment .