2018 CMS National Training Program (NTP) Workshop * indicates a required field. Forms submitted without the required fields completed will not be accepted. *Please select a location: Region VII: Kansas City, MO July 31– August 2, 2018 • Region II: New York City, NY August 6–8, 2018 • Region X: Seattle, WA August 14–16, 2018 • Region VIII: Westminster, CO September 11–13, 2018 • Region IV: Atlanta, GA September 5–7, 2018 • Registrant Information Prefix: * Dr. Mr. Ms. Mrs. First Name: * Last Name: * Credentials/Suffix: Job Agency: * Street Address: * Street Address 2: * City: * State: * ZIP Code: * Phone: Email: * *Which day(s) do you plan to attend? (Check all that apply) Day 1 (Understanding Medicare) Day 2 (Medicare—Beyond the Basics) Day 3 (Medicare Advanced Topics) *Number *Years of employees in your organization: of Medicare/Medicaid Experience: *Have you attended an NTP workshop before? Yes No If yes, how many? *Please check the boxes that apply to you. (Check as many boxes as necessary) State Health Insurance Assistance Program (SHIP, SHIBA) Federal Government Tribal Organization Health Insurance Plan/Agent/Broker Medical Professional (i.e., hospital, clinic, doctor, nurse, pharmacy) State or Local Government Agency Advocacy Organization (i.e., faith-based, condition-specific, ethnic or racial interest group)
2018 CMS National Training Program (NTP) Workshop * indicates a required field. Forms submitted without the required fields completed will not be accepted. *Please select a location: Region VII: Kansas City, MO • July 31– August 2, 2018 Region II: New York City, NY • August 6–8, 2018 Region X: Seattle, WA • August 14–16, 2018 Region VIII: Westminster, CO • September 11–13, 2018 Region IV: Atlanta, GA • September 5–7, 2018 Registrant Information Prefix: * Dr. Mr. Ms. Mrs. First Name: * Last Name: * Credentials/Suffix: Job Agency: * Street Address: * Street Address 2: * City: * State: * ZIP Code: * Phone: Email: * *Which day(s) do you plan to attend? (Check all that apply) Day 1 (Understanding Medicare) Day 2 (Medicare—Beyond the Basics) Day 3 (Medicare Advanced Topics) *Number of employees in your organization: *Years of Medicare/Medicaid Experience: *Have you attended an NTP workshop before? Yes No If yes, how many? *Please check the boxes that apply to you. (Check as many boxes as necessary) State Health Insurance Assistance Program (SHIP, SHIBA) Federal Government Tribal Organization Health Insurance Plan/Agent/Broker Medical Professional (i.e., hospital, clinic, doctor, nurse, pharmacy) State or Local Government Agency Advocacy Organization (i.e., faith-based, condition-specific, ethnic or racial interest group)