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REGISTRATION FORM
"EFFECTIVE, EFFICIENT, AND ETHICAL PRACTICE MANAGEMENT"
| Name:_________________________________________________________________ |
| License #__________________________________________ |
| Address:__________________________________________________________________________ |
| Phone:_____________________________________________ |
| Email:_____________________________________________ |
|
Circle One: | |
| $90-Professional Members | $120-Professional Non-Members (includes membership) |
| $45-Student Members | $60-Student Non-Members (includes membership) |
Selections (Circle one preference per time period):
| Sat., 8:30 AM-10:00 PM | Hochwalt | Osborn |
| Sat., 10:00 AM-12:00 PM: | Wilson | Taylor |
| Sat., 1:30 PM-3:30 PM: | Farnsworth | Wayman; Wantz |
| Sat., 3:30 PM-5:30 PM: | Wilson | Wantz |
Return To:
Amy Eiler, OMHCA President
155 S. Main Street
Centerville, OH 45458
Checks should be included with the registration form,
and made payable to the Ohio Mental Health Counselors Association
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