Course Registration Form

Name: Address: City: Zip: State: Phone: Cell Phone: Employer: Address: Position: Work Phone: Email (Print Clearly ): Check the Program you wish to register for:   ANA Nurse Executive Basic (NE-BC)   ANA Nurse Executive Advanced (NEA-BC)   ANA Professional Development (RN-BC)   ANA Medical-Surgical Nurse (RN-C)   AONE Certified Nurse Manager & Leader (CNML)   AONE Certified Executive Nursing Practice (CENP)   AACN Progressive Care Nurse (PCCN)   AACN Critical Care Nurse (CCRN)   ENA Certified Emergency Nurse (CEN)   ENA Certified Transport Nurse (CTRN)   ENA Certified Flight Nurse (CFRN)   NADONA Certified Director of Nursing Administration in Long Term Care (CDONA)   NADONA Certified RN-Long Term Care (RN-CLTC)   NADONA Certified LPN-Long Term Care (RN-CLTC) Date you wish to attend: Location where you wish to attend: Qualify For : - Select One - AACN or AONE Member ANA Member AACN Member ENA member Host facility staff member Non-member Group discount RSVP payment One day rate TOTAL DUE: $ Credit Card Payment Request: Name On Card:   MasterCard   Visa   Discover Credit Card Number: Exp. Date:  CVS Code:   Amount to charge: Date Signed:    Comments/Notes:

We will confirm receipt of your reservation and forward directions to your course location and contact info for our Staff that will be onsite in the event of an emergency.

If you have questions regarding pricing or group discounts, please call our office: 251-248-2857

Make checks payable to Petra Consultants and mail to the address listed below:

Petra Consultants, Inc.
P. O. Box 1941
Brewton, AL 36427
Phone: 251-248-2857
Fax: 251-248-2709

For Credit Cards email, mail or fax to:
251-248-2709

Another option, if you want to email your registration form, complete the form, sign it and scan it to your computer in PDF format and email to us at:

Lawanda@petraconsultants.net