THIS IS NOT AN ONLINE REGISTRATION FORM - FOR PRINT ONLY            Printed Date: 3/28/2024 8:11:19 AM

Seminar Title:
2-Day Intensive Trauma Treatment Certification Workshop: EMDR, CBT and Somatic-Based Interventions to Move Clients from Surviving to Thriving
Seminar Date:
Monday, January 20, 2020
Seminar Location:
BLOOMINGTON, MN 55431
Seminar ID:
76338

  Required (select one)
 
$499.99 Single Registration
$439.99 2+ Group Rate: per person
$429.99 5+ Group Rate: per person
$250.00 Student
  ________ HI, NM attendees add applicable sales and local taxes**
  ________ Subtotal (Required items + sales tax)
 
  Magazine Subscription
 
$12.99 Psychotherapy Networker Magazine Subscription - 1 Year (Full Price $36.00)
 
  Optional
 
$24.99 The Post-Traumatic Growth Guidebook: Practical Mind-Body Tools to Heal Trauma, Foster Resilience and Awaken Your Potential
$15.99 The Complex PTSD Workbook: A Mind-Body Approach to Regaining Emotional Control and Becoming Whole
$34.99 Trauma Treatment Toolbox: 165 Brain-Changing Tips, Tools & Handouts to Move Therapy Forward
$29.99 Trauma Treatment Toolbox for Teens: 144 Trauma-Informed Worksheets and Exercises to Promote Resilience, Growth & Healing
  ________ AL, AR, AZ, CA, CO, CT, DC, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, NC, ND, NE, NJ,
NM, NV, NY, OH, OK, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY attendees add applicable sales and local taxes**
  ________ Subtotal (Magazines + Optional items + sales tax)
   
  ________ Total (Required subtotal + Optional subtotal)
  ** Tax-exempt customers please send a copy of your tax-exempt certificate.
  *** Registration for coordinator or military member discount must be completed online
  **** All prices are shown in US Dollars ****
 
 

Please enter the MAIL CODE in the box below.

If you have a brochure, this code is found on the
back in the box above the address block.

If you do not have a brochure, please enter 888.

Mailcode Example
Mail Code or VIP #:
*  
First Name:
*     Last Name: *
Profession:
*
  Note: Leave Company/Department blank if providing home address
Company Name:
*
Department:
*
Address:
*
City:
*    State: *    Zip: *    County: *
Work Phone:
*      Cell Phone:   *      Fax Number:  
Email Address:
*    License Number: *
(required for confirmation of registration)

  Prepayment is REQUIRED
  Check enclosed
  Signed Purchase Order enclosed
Credit Card Type:
Mastercard    Visa    Amex    Discover
Credit Card #:
  V-Code #*
Exp Date:
/ *MC/Visa/Discover: last 3-digit # on signature panel on back of card
*American Express: 4-digit # above account # on face of card
Name on Card:
Mail or Fax to:
PESI, P.O. Box 1000, Eau Claire, WI 54702-1000      (800) 554-9775 (fax number)