Registration
REGISTRATION FORM
Name: ________________________________(SAME SPELLING IN YOUR PASSPORT)
TELEPHONE # ________________________ LICENSE #_______________________
HOME ADDRESS:_______________________________________________________________________
_______________________________________________________________________
E-MAIL: _________________________________(BOOKING INFO WILL BE e-MAILED)
EMPLOYER: _______________________________ DEPARTURE CITY: ____________
PLEASE ENCLOSE PAYMENT WITH REGISTRATION FORM(S). CHECK METHOD OF PAYMENT. CHECK
___________ FOR $ _________Make check payable to Nursing Education Int’l Concepts. CHARGE THE AMT.
OF $_____________ to my
VISA_______MC __________AMEX ________EXP. DATE: _______________________
CARD # _________________________ V-CODE _________MC/VISA Last 3 digit#
On signature panel on back of card. IF USING CREDIT CARD PLS. SEND COPY OF PICTURE ID (DRIVER
LICENSE) WITH REGISTRATION FORM(S). Pls. Add $85 more for credit purchase ( $2699 /$2299- are cash
discounted prices). Credit Card holder’s must be one of the passenger or CREDIT CARD payment will not be
accepted!!!!
Signature: ____________________________(by signing here you agreed to terms and condition regarding
refund, liabilities and importance of having travel insurance)
TOTAL PRICE: NY- $ LAX- $ _____________ BOSTON- $ _____________
OPTIONAL TOUR: _____________ SFO- $ ______________
OPTIONAL TOUR: _____________
OPTIONAL TOUR: _____________
INSURANCE: $250/PERSON _____________ OTHER- $ _____________
TOTAL: (PLS. ADD & REMIT PAYMENT) _______________
SEND YOUR REGISTRATIONS TODAY!!!!
DEADLINE: (see brochure)
FULL PAYMENT MUST BE RECEIVED BY DEADLINE DATE. SEND $500 -DEPOSIT TO INITIATE BOOKING (air,
hotel and cruise ) AND TO RESERVE YOUR SPOT. Pls. e-mail me if you would like a payment plan.
Please initial each box, sign and submit with your payment. Travel documents can not be sent if this form has
not been received. Travel documents will be mailed 2-3 weeks before the departure dates.
________I understand that it is my responsibility to obtain correct travel documents
( passport, VISA, identification) for the destination(s) to be visited.
________I understand that the names printed on the invoice must match exactly the first
and the last names in each passport. Any discrepancy may result cancellation,
changes fees, new & higher airfares or denial of service.
________I understand that I have an option (on my own) to purchase travel insurance. My
agent talked to me about the important of purchasing one. Please add $250 per
person if you want one from us... I declined __________(initial here)
________I understand that all disputes concerning this contract shall be resolved by
binding arbitration according to current rules of American Arbitration Ass.
________I have read and understand all the terms & condition including the terms of
cancellation & refund policies which maybe reviewed at:
www.nursingeducationinternationalconcepts.com. My payment and signature
constitute acceptance of those terms.
WE RESERVE THE RIGHT TO MAKE CHANGES IN THE PROGRAM (SEMINAR TOPICS) IN EMERGENCY
SITUATIONS!!!!
PLS. MAIL REGISTRATION FORM(S) TO: ATTN: ELENA CHATHAM RN,OCN,CCRN
NURSING EDUC. INT’L. CONCEPTS
4318 SADDLEHORN WAY
OCEANSIDE, CA. 92057
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