Name & Address
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Title
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First Name *
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Last Name *
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Suffix
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Name of company, institution, or practice
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Address *
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City *
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State *
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ZIP or Postal Code *
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Country
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Contact Information
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Office Phone *
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Fax Number
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E-Mail Address *
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Select Course
Please select course(s) for enrollment.
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Credit Card
Please enter credit card information. If you do not wish to use a credit card, please print this completed form, include your check, and mail to: IHRI, 600 Leighton Ave, Ste. C, Anniston, AL 36207
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Charge amount due to
my credit card (AMEX / Discover / Master Card/ VISA)
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Note: If you are eligible for a free course as a member, please login to your account and follow the “Free Course” link. Using this page will result in a charge to your credit card.
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