REGISTRATION  FORM
DR. IWATA WORKSHOP ATTENDING   [ x  ]   AUSTIN

Print Name [for certificate] __________________________________________________________

Job  Title ________________________________________________________________________

Agency _________________________________________________________________________

Address _________________________________________________________________________

City _________________________________________ State _______ Zip ____________________

Business phone (            ) _____________________ Fax # (            ) _________________________

E-mail __________________________________________________________________________


We offer continuing education credits [CEs] to Psychologists and Board Certified Behavior
Analysts [BCBAs, BCABAs & BCBA-Ds].   All others will receive a general Certificate of
Attendance.  

If you require a certificate which will comply with American Psychological Association [APA]
regulations or Behavior Analyst Certification Board [BACB]  rules, check the appropriate
box and follow instructions during registration.  

Psychologists will receive 11 CE credits.  BCBAs will receive 12 Type II CE credits.
  
Workshop registrants can receive both a Psychologist and a BCBA certificate for attending
this workshop.  
 

     Psychologist certificate   [   ]         BCBA  certificate [  ]   cert # ___________________

Mail or fax registration to ----   Behavior Intervention Specialists, Inc
  1739 University Ave,  Oxford, MS 38655   email    bisoxford@gmail.com

How are you paying?   Check in mail  [    ]    Purchase order  emailed or mailed  [   ]

                                We do not accept credit/debit cards