National Center of Continuing Education Order Form (offline)

Home of home study since 1977

For your convenience, you may type in the required information below, print this page and mail with a check, money order or credit card # to:

National Center of Continuing Education
P.O. Box 342588
Lakeway, TX 78734-9042

or Fax the form to 1-512-261-1397 or call Toll-free 1-800-824-1254 with credit card # to place your order.

(License Information is Required)

State Licensed: Renewal Date:

License #:

Name (First, Middle, Last):

Title: RN LVN LPN CST PT
Other:

Address (Mailing Address):

City:

State: Zip:

Daytime Phone:

Fax:

Evening Phone:

E-mail Address:

Check or money order enclosed.(Made payable to National Center of Continuing Education)

Charge the following credit card:

MC VISA AMEX OPTIMA DISCOVER

Card Number:

Expiration MM/YY:

I would like the following course(s):

Course #	Course Title	Contact Hrs	Price
			$
			$
			$
			$
			$
Shipping & Handling			$
FedEx (next day, add $30) No PO Box			$
Overseas Mail (add $30)			$
Certificate Fax Fee*			$
Grand Total			$

*For return of your certificate by Fax, add $7.00 plus $2.00 for each additional.

Thank you for your order!

COPYRIGHT © National Center of Continuing Education, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any mechanical or electronic means, photocopying, recording or otherwise, without prior written permission of copyright holder. "Convenience and a Choice..." is a service mark (SM) of the National Center of Continuing Education, Inc.