Name And Professional Information

First Name*

Initial

Preferred Name*

Last Name*

Sex*
FemaleMale

Date of Birth*
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Degree*
MDDODDSPAOther

State Issuing Medical License*

Medical License Number*

Specialty 1*

Specialty 2

Contact Information

Primary Email*

Military personnel and government employees must list a non-work email address for their primary email.

Secondary Email

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Personal Phone*

Please use the format 555-555-5555 for US phone numbers.

Work Phone

Please use the format 555-555-5555 for US phone numbers.

Military Personnel & Government Employee Applicants Only

Service Branch
—Please choose an option—Air ForceArmyMarinesNavyVACivilian EmployeeOther

Military Rank

Date of end of obligated service
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Tuition*

300-Hour CME course: $12,000 by credit card, $11,750 by check($12,500 after 10 November 2020)Full-time Resident or Fellow: $10,000 by credit card, $9,750 by check($10,300 after 10 November 2020)

Indicate method of payment:*

CheckPreferred - Payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704Credit Card - onlinePay online at https://mkt.com/hmiCredit Card - by phoneCall 510-649-8488 between 9am and 2pm Pacific Time or fax to 510-649-86923rd Party PaymentSpecify:

All training activities will take place at the Tempe Mission Palms Hotel & Conference Center, Tempe, AZ. You are requested to lodge at the hotel where a group rate has been arranged. A conference day use fee of $89 per day is required of participants who choose to stay elsewhere or room with another course participant.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com.

Your personal check will not be deposited until you have been accepted to the course.

Once you have submitted this online application you will receive a confirmation email.