CEU Applications Purchase "*" indicates required fields Step 1 of 3 - Facility Details 0% Hospital / Facility*Primary Contact* First Last Phone*Email* CEU Certificates will be emailed to this address.Billing Address* Street Address Address Line 2 City State 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 ZIP Code CEU Application Credits*Select the amount of application credits based on your predicted number of continuing education applications that you will use this calendar year. Each date will count as an application. Any unused credits are NOT transferable to the next year.1 Application (Credit)4 Applications (Credits)10 Applications (Credits)15 Applications (Credits)20 Applications (Credits)25 Applications (Credits)30 Applications (Credits)35 Applications (Credits)40 Applications (Credits)Unlimited Applications (Credits)Total Payment Method*Credit CardCheckPayment must be received prior to program approval. Make checks payable to: Arizona Society for Respiratory Care Mail to: 1959 S. Power Rd. Suite 103-292 Mesa, AZ 85206Credit Card*Feed Required: To use the Stripe field, please create a Stripe feed for this form. Spam Check: What goes up, must come ____.*Please complete the phrase in order to submit your request.