CEU – 8 hrs. Continuing Education Consent Form (8 hrs) Advanced Laser Institute919 West Gray St. Houston, TX 77019Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Email(Required) State Board License Number(Required)Please Upload Valid Driver License(Required)Max. file size: 128 MB. Continuing Education (8 hrs.)Course Price: $100Students will have the option to choose from any of the Continuing Education courses offered by Advanced Laser Institute, which add up to 8 hours, in order in order to meet the requirements for license renewal. Method of Payment(Required)Credit/Debit CardPayPalZelleAny holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor shall not exceed the amounts paid by the debtor hereunder. “Electronic SignatureName First Last Date MM slash DD slash YYYY
