National Laser Institute Registration Form
National Laser Institute Unique

Enrollment - Check all that Apply

Scottsdale, Arizona

A.) Laser and Intense Pulse Light Classroom/Didactic
B.) Laser Hair Removal Course
C.) Laser Essentials
D.) Comprehensive Laser Plus
E.) Just Tattoo Removal (3 Day)
F.) Fractional Plus, Tattoo Plus or Ethnic Skin Course

Las Vegas, Nevada

A.) Core Training Course
B.) Advanced Training Course

CME Aesthetics Weekend Course - Arizona Only

A.) Laser Essentials and Advanced Laser
B.) Injectables: Botox and Dermal Fillers

CME Aesthetics 7 Day Course - Las Vegas, NV

A.) 7 Day Comprehensive Course (5 Day Laser, 2 Day Injectables)

CME Advanced Aesthetics Botox and Fillers

A.) Advanced Skin Rejuvenation - Botox and Fillers
B.) Sclerotherapy

  Reserve My Seat Deposit: $250 (Fully Refundable)
 
Course Date ___________________
Name:__________________________________ Address:____________________________________________________
_____________________________________________ City:_____________________    State:_____    Zip: _________
Home Phone: (_____) _____________________________    Work Phone: (_____) _______________________________
Cell Phone: (_____) _______________________________    Email: __________________________________________

Help us serve you better; complete the following questions to your best ability:

Education:__________________________Work History:________________________________________________________
I am currently: Unemployed   Employed   Employer Name: ____________________________________________________
I am a: (cert or education not required) MD   PA   MA   RN   Aesthetician   Student   Other: ___________________

How did you hear about us? (check all that apply)

Internet:   Which search engine did you use? (ie: Google, Yahoo) __________________________________________
Which Keywords did you use: (ie: laser school)_________________________________________________________________
Print Advertisement   Article   Postcard/Mailing   Seminar   TV   Trade Show Other ________________________
(Referral) Name:___________________________________ (School) Name:_________________________________________

Payment

Tuition: _____________________________________    Payment Total: _______________________________________
Check ________ Credit Card (Visa, MasterCard, Discover,& American Express) ___________ Other _______________
Card Number_________________________    Expiration Date_______________________    CCV # ________________
Name on Card: ___________________________________    Signature: ______________________________________
Billing address (if different from above)
_______________________________________________________________________________________________

Print form and fax it to 480.222.4385.