Chinese Medicine Doctor

Name:
Address:
City:	State: Zip:
Daytime phone:
Nighttime phone:
Fax:
E-mail:

I am a California Licensed Acupuncturist Chinese Medicine Doctor

I am a Registered Nurse

I am a

I need proof of completion for CEU¡¦s

I am including my credit card number for payment in the amount of $

Credit Card Number: Expiration Date:

Signature______________________________________________________________
(you may fax or call with your credit card number)

I have enclosed a check of my registration fee for the total amount of $

Please make check payable to University of East-West Medicine and send to:

University of East-West Medicine
970 W. El Camino Real
Sunnyvale , CA 94087

ATTN: CEU Registration