REGISTRATION FORM
DR. IWATA WORKSHOP ATTENDING [ x ] CHARLESTON, SC
Print Name [for certificate]__________________________________________________________
Job Title ______________________________________________________________________
Agency _______________________________________________________________________
Address _______________________________________________________________________
City _______________________________________ State _______ Zip ____________________
Business phone ( ) _____________________ Fax # ( ) _______________________
E-mail ________________________________________________________________________
We offer continuing education credits [CEs] to Psychologists and Board Certified
Behavior Analysts [BCBAs, BCABAs & BCBA-Ds]. All others will receive a general
Certificate of Attendance.
If you require a certificate which will comply with American Psychological Association
[APA] regulations or Behavior Analyst Certification Board [BACB] rules, check the
appropriate box and follow instructions during registration.
Psychologists will receive 11 CE credits. BCBAs will receive 12 Type II CE credits.
Workshop registrants can receive both a Psychologist and a BCBA certificate for
attending this workshop. If you do not request a BCBA or Psychology certificate in
advance, there will be a $10 charge, payable at the workshop, by cash or check.
Psychologist certificate [ ] BCBA certificate [ ] cert # _________________
Mail or fax registration to ---- Behavior Intervention Specialists, Inc
1739 University Ave, Oxford, MS 38655 fax (662) 234-0553
How are you paying? Check in mail [ ] Purchase order to be faxed or mailed [ ]
We do not accept credit/debit cards