Registration Form: The IC-EC Connection

Sign up online if paying by credit card. Or send your check along with this completed registration form to: Joint Commission Resources, P.O. Box 75751, Chicago, IL 60675-5751.

Registration Information:

Name (Please include any professional credentials):

______________________________________________________

Title:

______________________________________________________

Organization Name:

______________________________________________________

Address:

______________________________________________________

City/State/Zip:

______________________________________________________

Telephone Number (including area code):

______________________________________________________

Fax Number (including area code):

______________________________________________________

E-mail Address:

______________________________________________________

Indicate Method of Payment:

Note: Payment in U.S. dollars must accompany completed registration form. Registration forms received without payment will not be processed until payment has been received. Prices subject to change without notice.

_____ Check, payable to Joint Commission Resources (check must accompany registration form)
_____ VISA
_____ MasterCard
_____ American Express

Registration Fee:

_____ $249 per connection

Credit Card Number:

______________________________________________________

Cardholder's Signature:

______________________________________________________

Cardholder's Name:

______________________________________________________

Expiration:

______________________________________________________

Telephone Number (including area code):

______________________________________________________