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2025 June NC EAPA Virtual Training Registration – Membership Appreciation Training

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Registration Date

MM slash DD slash YYYY

Name:*

Prefix First Last

Organization / Company Name*

(who you are representing)

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

EAPA-NC Membership #:*

(if non-EAPA member, please enter “0000”)

CEAP:

Yes

LCMHC:

Yes

Please list other licenses/certifications:

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Please indicate how you will attend:*

In Person

Virtual

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Guest Name (bring a friend for free)

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Please indicate how your guest will attend:

In Person

Virtual

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Guest Email (needed for virtual attendees)

Fees:*

Half-Day Members $0.00

Half-Day Non-members: $42.50

Full-day Member $0.00

Full-day Non-Member $85.00

How will you be paying?*

Check

Pay Pal

There are no refunds.

Kerry Paksoy, Assistant Treasurer NC EAPA
5525 Overleaf Court
Raleigh, NC 27615
paksoyk@gmail.com

Total

Payment Method

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

Card Number Expiration Date Security Code Cardholder Name

**Note: Clicking the Submit button will forward your information for registration to this conference and email confirmation to you, but will also launch a PayPal web page. If you plan to pay with cash or check in person, then you can close the following PayPal page. Only continue with the PayPal page if you plan to pay online.

THERE WILL BE NO REFUNDS

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