Student Information

Event/Class _____________________________________________
Student name ____________________________________________
Designations _____________________________________________
Social Security Number _____________________________________
Your e-mail address _______________________________________

First time to attend:
___ CIC Institute
___ CIC Institute in KY
___ CISR Seminar
 

Registration Type:
___ PIA Member
___ Nonmember
___ ADA Special Need
___ CE Credit Needed

Is this a CIC or CPSR update? _________
 

Firm Name _____________________________________________
Street Address __________________________________________
Mailing Address _________________________________________
City, State, Zip __________________________________________

Office Phone (include A/C) ________________________
Home Phone (include A/C) ________________________
FAX (include A/C) _______________________________
Your e-mail address _____________________________

Credit Card Number _____________________________
Expiration Date ________________________________
Name on Card _________________________________
Type of Credit Card _____________________________

Signature of Cardholder __________________________________

CISR Cancellation Policy:
CIC: Cancellations received 5-14 days prior to an institute are subject to a $125.00 cancellation fee. Cancellations received less than 5 days prior to an institute are non refundable. For any refund to be made, written notice must be sent to PIAK.

CISR Cancellations received 5-14 days prior to a class are subject to a $45.00 cancellation fee. Cancellations received less than 5 days prior to a class are non refundable. For any refund to be made, written notice must be sent to PIAK.

Transfer Policy
CIC: A $50 fee will be charged if you transfer your registration to another institute. Class transfer must stay in same PIAK fiscal year.

CISR: A $25 fee will be charged if you transfer your registration to another class. Class transfer must stay in same PIAK fiscal year.

DA:
In accordance with Title III of the American with Disabilities Act (ADA), we invite all registrants to advise us of any disability and any requests for accommodation to that disability.  Please submit your request as far as possible in advance of the program.