CEs Request – The Melissa Institute

Your Name:

Contact Address:

City:

State:

Zip:

Your Email:

License Types:

LCSWLMHCLMFT

License number:

State of License:

CE Registration Payment

$ Donation Amount:

Custom Amount

Make this donation every

Personal Info

First Name *

Last Name

Email Address *

Credit Card Info

This is a secure SSL encrypted payment.

Card Number *

CVC *

Cardholder Name *

Expiration *

Billing Details

Country *

Address 1 *

Address 2

City *

State *

Zip / Postal Code *

Donation Total: $35.00 One Time

Note: Payment is required to process CE credits. You must register through zoom as well as through our website to receive the presentation link. Please be on the lookout for an email from Zoom and check your spam/junk email if you have not received it. We recommend saving this zoom link. Please contact us at info@melissainstitute.org if you have any issues or concerns.