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
*
First Name
Last Name
Q.2
APIC Member ID (if applicable)
Q.3
What location are you interested in attending?
*
Chicago
Springfield
Q.4
Hospital Affiliation
*
Q.5
Facility Name
*
Q.6
Please provide your city/town, state and zip code
*
City
State
Zip Code
Q.7
Email Address
*
Email