PRINTABLE HMI APPLICATION FORM

tel: (510) 649-8488
fax: (510) 649-8692

*RETURNING WARRIOR APPLICATION FORM* 2009 Clinical units
COMPLETE FORM ONSCREEN, THEN PRINT OUT. MAIL OR FAX COMPLETED FORM AND PAYMENT TO: Helms Medical Institute 2520 Milvia St., Berkeley, CA 94704 Fax: 510-649-8692 For additional information concerning this program call: 510 649-8488 or email: MAFP@HMIeducation.com Enrollment is limited - early application is recommended.
Please enclose with this application form: a small current photo			a resume and/or update statement
Name:	(First, Middle initial, Last)		Day Phone:
			Home:
Address:	(Street Address Only, No P.O. Boxes)		Fax: Email:
City:		Field of Practice:
State:	Zip:
Video Course Format:	300-hr 220-hr	Specialty videos:	Pain Management Primary Care
SELECT THE CLINICAL UNITS YOU WISH TO ATTEND. You should plan to attend both Clinical I and Clinical II in sequence. Select either the Spring 2009 or Fall 2009 sessions below:
Spring 2009: Fall 2009:	Clinical I: March 20-24, 2009 in Pittsburgh, Pennsylvania Clinical II: May 20-24, 2009 in Tempe, Arizona Clinical I: September 18-22, 2009 in Pittsburgh, Pennsylvania Clinical II: December 2-10, 2009 in Tempe, Arizona

fee: $2000 for two 5-day units, (recommended) or $1500 for one 5-day unit.	Check payable to: Helms Medical Insitute
	Charge (MasterCard, Visa, or Discover only)
Card Number: - - - Expiration Date:
Authorizing Signature: ____________________________ Date:__________________
* By Regental authority your Social Security# is required in order to verify your identity for accurate recordkeeping. Providing your birth date is voluntary.