Wake AHEC Duplicate CE Credit Certificate Request

Credit card payment is required, secured, and confidential.  We accept American Express, VISA, MasterCard, and Discover.  Please have your credit card ready.  A Wake AHEC customer service representative will process your request.  If you have any questions or concerns, please call 1-866-341-1814 (toll free) or (919) 350-8547 during business hours:  9am - 4pm (US, Eastern Time), Monday - Friday. 

To help us find your record, please enter your information on this form.
 
*Required Fields  Program Information
*Date of Program:
*Name of Program:
 * Required Fields   Your Information
 *Name:
First Name Initial Last name
 Name changes not allowed on registration.
 To correct your name, close this window and go back to your
 MyAHEC dashboard, Under Profile, click Contact Information.
 Each registrant must have their own MyAHEC account.
 Make sure you are logged in to the correct account or credit will
 not be applied correctly.
Salutation: Mr. Mrs. Ms. Dr.
*Degrees/Certifications:
   If not applicable, enter NA.
*Home address:
 
*City:
*State:     *Zip:
 *Phone (Home): ()   -
*Occupation:
NABP e-Profile ID: Pharmacists and Pharm Techs only
Birth - MMDD: Pharmacists and Pharm Techs only
Employer:
County of Work:
Work address:
 
Work City:  
Work State:       Work Zip:
 Phone (Work): ()   - Ext.
 Fax (Work): ()   -
 Would you like to receive program announcements?
  Check to receive announcements
*Email (Home or Office):
Valid Email address required
*How did you hear  about Wake AHEC?
 
 How do you prefer to receive your certificate?
(check one only)

Fax (7-10 business days)
eMail to my home (up to 5 business days)
eMail to my work (up to 5 business days)



* Please enter the letters and/or numbers you see above:

 

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 Fees
$15.00