If you would like to register for a course, please fill out the form below, print it out, and enclose a check or credit card (MC, Discover, or Visa) payment and mail to QUEST, 25 Mountain Rd, Burlington, MA 01803 or fax credit card payments to our private dedicated fax line (781) - 272 - 8476 . If registering late (within 2 weeks of course date), add an additional $30 to the listed tuition price. Please await written confirmation before making any non-refundable (air) travel plans.

Personal Information

Name:
Title:		PT OTR PTA COTA Nurse ATC Other
Home Address:
Apt:
City:
State:
Zip:
Phone:		(Include Area code)
Professional License # :		(Optional for CEU's, please include state and number)

Please indicate course, date, and location:

Course:
Location:
Date:
Late Fee $30		(if registering 2 weeks of course date)
Special Discount:

Payment Information

Total Amount Enclosed:
$ (tuition, minus discount, plus late fee)
Name as it appears on Credit Card:
(MC/Discover Card or Visa only)
Credit Card #:

Expiration Date: Month Year
I authorize QUEST to charge my account:

If you wish to receive a confirmation by email, put your email address here: