CE Presentation and Open House Registration Form

In honor of Recovery Month and in celebration of the opening of Twin Lakes Recovery Center…
Please join us on Friday, September 16, 2016 for a Complimentary CE Presentation and Open House.

For details about either event, please see our Events page. We hope to see you there!

Name:*
First Last
Company or Practice Name:*
Email:*
Phone:*
Will You Be Attending the CE PRESENTATION?*
- Yes
- No
Address:*
Street Address Address Line 2 City State ZIP Code
CE Type:*
Please Specify CE Type:*
Credentials:*
As they should appear after your last name
Professional License Number:*
Required for reporting to CE Agencies
Will You Be Attending The OPEN HOUSE?*
- Yes
- No
Number of People Attending:*
Would You Like To Be Added To Our Email/Mailing List?*
- Yes
- No
Email
This field is for validation purposes and should be left unchanged.