REGISTRATION FORM - AUDIOMETRY TRAINING & CERTIFICATION

Name and Title________________________________________________________

Company_______________________________________________________________

Street________________________________________________________________

CITY, STATE/ZIP_______________________________________________________

Phone_________________________________________________________________

FAX___________________________________________________________________

Home Phone____________________________________________________________

Course Date__________________Location___________________________________

Audiometer Type Used:_________________________________________________

Please call our office if you plan to bring your own equipment.

Registration Fee: $595  Please send a check along with this registration form

Due 2 weeks prior to course. No refunds but transferable. 

Mail To:


MEDI

Attn: Dr. Fankhauser

4818 E. 2nd St,

Benicia, CA

94510

Phone: (800) 736 6334
Fax:   (707) 746 6374

Make checks payable to: Palmer Associates Inc.