LEGAL NURSE CONSULTING COURSE REGISTRATION FORM Register before February 1 and Save $200 Course Registration Fee: $2,495 Please mark which session you are registering for: 16SNU600AN: Gulfport, Miss. 16SNU600BN: Metairie, La. 16SNU600CN: Mobile, Ala. 16SNU600DN: Baton Rouge, La. Mar. 5; Apr. 2; Apr. 30; May 21 Mar. 11; Apr. 1; May 6; Jun. 3 Mar. 18; Apr. 22; May 20; Jun. 10 Mar. 12, Apr. 23; May 7; Jun. 4 Name: Street Address: City/State/Zip: Day Phone: Email: Cell Phone: Employer: RN License No. For award of nursing contact hours STATE: Method of payment: Total amount: Check or Money Order payable to USA Center for Continuing Education Please charge my: Card Number: Security Code: VISA MasterCard American Express Discover Expiration Date: AMEX code is 4 digits, all others are 3 / (Month/Year) Billing Address (required): Signature: Cardholder’s name: Remit completed registration form to: University of South Alabama Center for Continuing Education 555 University Blvd. N. / AHE 232 Mobile, AL 36688 Fax: 251.460.7709 REFUND POLICY: All course fees will be refunded if written notification of cancellation is received at least 10 business days before the course begins. All course fees will be refunded if course is cancelled due to low enrollments. No refunds will be granted once the course has begun. The University of South Alabama does not discriminate in its student and employment practices in violation of any applicable laws. The University of South Alabama is an Equal Opportunity Employer - Minorities/Females/Veterans/Disabled. In accordance with the American’s with Disabilities Act, please advise us when you register for the course if you have any disability that requires special materials and/or services so that the appropriate personnel can be advised to arrange the needed accommodations.