CE Enrollment Form

The Rhode Island Psychological Association

Continuing Professional Education Program
Registration Form

Please print and mail completed form with payment to:
RIPA CPE Program Enrollment
1643 Warwick Ave., PMB 103
Warwick, RI 02889

Name: __________________________________________ Degree: ________

Discipline: ______________________________________

Address:_____________________________________________

City:______________________________ State:____ Zip:_____________

Daytime Phone:_________________ Fax: ___________________

Email: _________________________________________________________

CE Program Title	Member Rate	Non-Member Rate

1) ____________________________________________	__________	__________

2) ____________________________________________	__________	__________

If postmarked within 7 days of Program, add $20.00	__________	__________

Deduct special discount if applicable*	__________	__________

TOTAL PAYMENT ENCLOSED:	__________	__________

*A special discount may sometimes be offered to individuals registering for two programs at the same time -- see details provided for each program to determine availability and amount of discount

Make checks payable to: RIPA CPE COMMITTEE

If you have any questions or would like additional information, please contact the RIPA CPE Committee at (401) 736-2900.

Thank you for your participation!