Utah State Bar CLE Dept>>>

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Basic Medicaid Training
2/8/2013

There are three ways to use this form :

1 - Fill it out, print it and mail with your check to:

Utah State Bar, CLE
645 S. 200 E. , Suite 310
Salt Lake City, Ut. 84111
*There will be a $20.00 charge for returned checks.

You may also pay by check at the door.

2 - Fill it out, print it and FAX it to the CLE Department at: (801) 531-0660.

3 - Fill it out and hit the SUBMIT button. The form information will be automatically sent to the Utah State Bar. (While this method is safe since the information is going from your computer to the Bar Email Server it is not an encrypted server transaction. If you are uncomfortable with this please use either options 1 or 2)

Please note that all RSVPs via email are confirmed within 48 hours. If you have questions related to this event, please call (801) 297-7036 or email cle@utahbar.org.

Fields with an * are required for the form to submit.

CANCELLATION POLICY

Cancellations must be confirmed in writing at least 48 hours prior to the seminar date. If cancellation is made within the time period, the registration fee will be returned to the registrant. No refunds will be given for cancellations made after that time. The full registration fee is due and payable to the Utah State Bar if you register but do not attend.

Name *
Bar Number *
Street Address
 
City
State & Zip
Phone
Fax
Email Address *
Cost(s) $45.00 for all

Payment Information

Visa
MasterCard

Cr Card #:
Exp Date Mo/Yr : CVC:

Personal Card
Corporate Card

Billing Address

SAME AS ABOVE

Other Billing Address: