National Laser Institute Registration Form
National Laser Institute Unique

Enrollment - Check all that Apply

Scottsdale, Arizona

A.) Laser and Intense Pulse Light Classroom/Didactic
B.) Laser Hair Removal Course
C.) Laser Essentials
D.) Comprehensive Laser Plus
E.) Just Tattoo Removal (3 Day)
F.) Chemical Peel, Fractional Plus, or Tattoo Plus
G.)Core 8-Day Training Course

CE/CME Medical Aesthetics Comprehensive

7 Day CME: Botox, Fillers & Laser
5 Day Comprehensive Laser Only

CE/CME Injectables: Botox, Fillers, Sclerotherapy and Peels

Weekend CME: Botox, Dermal Fillers, Sclerotherapy
Additional Chemical Peel Day

  Reserve My Seat Deposit: $250 (Fully Refundable)
 
Course Date ___________________
Name:__________________________________ Address:____________________________________________________
_____________________________________________ City:_____________________    State:_____    Zip: _________
Home Phone: (_____) _____________________________    Work Phone: (_____) _______________________________
Cell Phone: (_____) _______________________________    Email: __________________________________________

Help us serve you better; complete the following questions to your best ability:

Education:__________________________Work History:________________________________________________________
I am currently: Unemployed   Employed   Employer Name: ____________________________________________________
I am a: (cert or education not required) MD   PA   MA   RN   Aesthetician   Student   Other: ___________________

How did you hear about us? (check all that apply)

Internet:   Which search engine did you use? (ie: Google, Yahoo) __________________________________________
Which Keywords did you use: (ie: laser school)_________________________________________________________________
Print Advertisement   Article   Postcard/Mailing   Seminar   TV   Trade Show Other ________________________
(Referral) Name:___________________________________ (School) Name:_________________________________________

Payment

Tuition: _____________________________________    Payment Total: _______________________________________
Check ________ Credit Card (Visa, MasterCard, Discover,& American Express) ___________ Other _______________
Card Number_________________________    Expiration Date_______________________    CCV # ________________
Name on Card: ___________________________________    Signature: ______________________________________
Billing address (if different from above)
_______________________________________________________________________________________________

Print form and fax it to 480.222.4385.