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Seminar Registration Seminars 2000 Attention: Lyndsey Herrman, FSHS, MSW 8511 SW 51st St. Topeka, KS 66610 Phone: (785) 845-8455 Fax: (785) 478-0181 Please fill out registration form on-line and then print it out and Fax it or mail it with your check Pre-registration is required. Your E-mail: Profession: Social Work Psychology Pyschiatry Professional Counselors Marriage & Family Therapist Drug & Alcohol Abuse Counselor Case Manager Mental Health Professional Other First Name: Last Name: Organization Name: Work Phone number: - - Home Phone number: - - Mail Address: City: State: (Select your state) Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Island Virginia Washington West Virginia Wisconsin Wyoming Postal Code: - GROUP RATES AVAILABLE (6 or more) Call - (785) 845-8455 Register BEFORE Feb 5 2008 - Take $5 off per Seminar* Select Seminar: April 18, 2008 - Topeka Kansas: [$89]"HOCUS POCUS DIAGNOSIS" April 25, 2008 - Overland Park Kansas: [$89]"HOCUS POCUS DIAGNOSIS" May 9, 2008 - Wichita Kansas: [$89]"HOCUS POCUS DIAGNOSIS" Cancellations: Less 80% is refundable up to 14 days prior to the workshop. After 14 days prior registration full amount is non-refundable Late Enrollment: Registration Deadline is 9 days prior to the workshop. Late fee of $10.00 will apply if received less than 9 days before the workshop. Enclosed is my check payable to CEUOutlet for $ Please Charge My Credit Card $ Visa      Mastercard Credit Card Number: _________ - _________ - _________ - _________ Expiration Date: _________________ Provide Other Information or Feedback Here: Check this box if you would like to recieve a call

Questions About Seminars or Ordering Study materials? Call Lyndsey Herrman, FSHS, MSW Phone: (785) 845-8455 Fax: (785) 478-0181