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Application Process: Send completed application with payment to:

Neuro-Rehabilitation Training & Education
P.O. Box 153130
San Diego, CA 92195

Applicants who meet the stated requirements will be accepted in the order received.

Please check course applying for.

Name: ____________________________________________
Profession: ________________________________________
Mailing Address: _________________________________________________________
City: ___________________________________________________________________
State: ____________________________________ Zip Code:________________
Phone: (H) _______________(Cell) ___________________(W) ______________
e-mail: _________________________________________________________________
Professional Schools Attended: (optional)______________________________________________
Date Graduated: __________________________________________________________
Current Position: _________________________________________________________
Hours of direct patient contact per week: ____________________________
Type of facility: __________________________________________________________
Total years of experience with Hemiplegia:_____________________________________

If paying by check please make check payable to:                                    Neuro-Rehabilitation Training & Education
If paying by credit card please fill out section below.
Type of card circle:   Visa     Mastercard     American Express
Amount to be billed to credit card $ _____________________
Credit Card # ______________________________________                   security #on back __ __ __
Expiration Date: _________________________________________________________
Name on Credit Card: _____________________________________________________
Billing Address: __________________________________________________________
Signature: _______________________________________________________________