Register – Bayside CEU

Name

Username*

First Name*

Last Name*

Contact Info

Primary e-mail*

Secondary e-mail

About Yourself

Password*

Repeat Password*

Date of Birth

Organization

Daytime Phone*

Evening Phone

Fax

Address 1*

Address 2

City*

State (or Province)*

Zip Code*

Country*

Your Organization's Access Code If this pertains to you, this code would have been given to you by your EMPLOYER to allow you free access to the site. You can find this code on any informational material at your organization.

How did you hear about us?*

Other

Professional Information

If licensed please complete. If not fully licensed or only provisionally licensed as an intern please leave this section blank.

State of Licensure or if not licensed state of residence*

License Number 1* (PLEASE START with the letters preceding your license number (e.g. RN33345). If you do not have a license please write NONE in the box.)

Renewal Date (mm/yy)

License Number 2 (PLEASE START with the letters preceding your license number (e.g. RN33345))

Renewal Date (mm/yy)

License Number 3 (PLEASE START with the letters preceding your license number (e.g. RN33345))

Renewal Date (mm/yy)

* ATTENTION FLORIDA, OHIO, AND SOUTH CAROLINA LICENSEES: You must enter your professional information above in order for your credit to be reported to the state. Additionally, the name on your account MUST MATCH the name on your license. If you are unable to correctly enter your license information, please email contactus@baysideceu.com with your license information.

By clicking ‘Register’ you agree that you have read and accept the Customer Agreement