TSCPA - CPE Registration Printout Form

CPE Registration Printout Form

Name: ________________________________________________________________

CPA Certificate #: _______________________________________________________

Firm: _________________________________________________________________

Address: ______________________________________________________________

City: _______________________ State & Zip Code: ___________________________

Business phone:_________________________________________________________

E-mail: ________________________________________________________________

Check one category:

Pay member fee if you are a TSCPA
member, other state society member, or
non-CPA staff of a member of TSCPA.

Society Name:___________________________

Pay nonmember fee if you are licensed in
Texas but are not a member of TSCPA

Program Title:
____________________________________

Program Number: ____________________

Program Date: _______/_______/_______

Program City: _______________________

Program Price: $_____________

Program Title:
____________________________________

Program Number: ____________________

Program Date: _______/_______/_______

Program City: _______________________

Program Price: $_____________

Program Title:
____________________________________

Program Number: ____________________

Program Date: _______/_______/_______

Program City: _______________________

Program Price: $_____________

Program Title:
____________________________________

Program Number: ____________________

Program Date: _______/_______/_______

Program City: _______________________

Program Price: $_____________

Total Program Price: $_____________

I have special needs under the Americans with Disabilities Act. ** Attach a written description.

Payment Method (select one)

Check American Express, Visa, MasterCard

Card Number: _______________________________________________________________

Card Expiration Date: _______/______/________ Charge Amount: $_____________________

Cardholder's Name: ________________________________________________________

Cardholder's Signature: ______________________________________________________

Mail your payment & registration form to:

TSCPA CPE Foundation
P.O. Box 797308
Dallas, Texas 75379

Fax to:

800.207.0273
In Dallas: 972.687.8696

Call the CPE InfoLine at 800.428.0272 (972.687.8500 in Dallas) for more information.