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  COLUMBUS  [  ]    SAN JOSE  [  ]    ANAHEIM   [  ]

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.   Certificates will be on the registration table at the end of
the second day of the workshop.  PICK UP YOUR CERTIFICATE.  This is our method of
assuring that participants attend the entire workshop.

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

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

We do not accept credit/debit cards

IF YOU NEED A W-9 FORM, CLICK HERE

REGISTRATION  FORM