Due to overwhelming demand, both the Chicago and Springfield LTC Certificate Courses are full. To be added to the wait list, please complete this brief form.

Q.1
Full Name *


Q.2
APIC Member ID (if applicable)

Q.3
What location are you interested in attending? *

Q.4
Hospital Affiliation *

Q.5
Facility Name *

Q.6
Please provide your city/town, state and zip code *



Q.7
Email Address *