Application for Enrollment Nurses & Medical Assistants Liposuction 101 Please Print & Submit this Application by Fax: 949-248-9339
Last Name __________________	First Name _______________	MI__________
Degree (circle one): RN or Other ________________________________
Date of Birth (mm/dd/yyyy) _________________
Street Address ________________________________________________________________
City __________________________	State/Province ______________	ZIP___________
Telephone (Office) ____________________		Tel (Home) _____________________
Fax: _______________________________		E-Mail _________________________
Have you ever been disciplined by a state licensing board?						No	Yes
Have you ever had medical malpractice insurance canceled, or limited?						No	Yes
Have you had chemical abuse or dependency within the past 5 years?						No	Yes
Name of Surgeon with whom you work ___________________________________________
Size of Surgical Scrubs/Gown (circle one): Extra Small , Small , Medium , Large , X Large , XXL , XXXL
Dates of Course for which you are applying? _______________________________________
How did you hear about Liposuction 101? _________________________________________
___________________________________________________________________________
Required Text: Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction, by Jeffrey Klein, Mosby, 2000 can be purchased on-line at hksurgical.com or by telephone at 800-909-0060
Refund Policy
If notice of cancellation is given 6 weeks (42 days) prior to the course starting date, then the deposit will be refunded minus a $100 handling fee.  If notice of cancellation is given less than 6 weeks prior to course starting date, then the entire deposit will be forfeited. However if it is possible to find a replacement student then only $100 will be forfeited.
CEU Credit
The California Board of Nursing certifies that this educational activity has been recognized for up to 24 hours of credit for Continuing Education Units.
Nursing Course Concurrent with Surgeons Liposuction 101Course Concurrent with Liposuction 101 for Surgeons, up to six nurses may take an abbreviated 2-day Nurses' Tumescent Liposuction Course (Nurses' TLC). There is no charge for this course for nurses (there is a $500 fee for each registrant which will be refunded after the nurse attends the course). Surgeons may bring one additional nurse for the Nursing TLC for a fee of $1000 pending space availability. This course is made available on a first-come basis. Nurse applicants must also complete the above application form. Telephone for information about Nursing TLC 949-369-2594.
Nursing Course given at a different time than the Surgeons Course The course fee is $ 2,500 (50% discount is given if employer has attended the course for Surgeons). The course fee may be paid in two (2) installments. The first payment of $500.00 should accompany the application and supporting documents. The balance is due at least 6 weeksprior to the first day of the course. If payment is not completed on time, the course will be offered to the next person on the waiting list.
Signature of Applicant____________________________________________
For Further Information: Telephone 949-369-2594, Mailing Address: 30280 Rancho Viejo Road, San Juan Capistrano, CA 92675, USA