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Name_______________________________________________ Soc. Sec. #_________________
Please Print: First MI Last Address________________________________________________________________________ City________________________________ State ________________ Zip___________________ Charge to: ____Visa ____MasterCard ____American Express Card #___________________________ Exp. Date __________ Note: Credit card payments may be used for fax or phone-in grading only. Signature____________________ Soc. Sec. #_____________ Daytime Phone ______________ State License(s)__________________ Is this a new address? Yes ____ No ____ |
| Check one: |
____ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.)
____ I am not enrolled. Enclosed is a $20.00 check payable to Podiatry Management Magazine for each exam submitted (plus $2.50 for each exam if submitting by fax or phone). ____ I am not enrolled and I wish to enroll for 10 courses at $129.00 (thus saving me $71 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. |
| Circle: |
1. A B C D
2. A B C D 3. A B C D 4. A B C D 5. A B C D |
6. A B C D
7. A B C D 8. A B C D 9. A B C D 10. A B C D |
11. A B C D
12. A B C D 13. A B C D 14. A B C D 15. A B C D |
16. A B C D
17. A B C D 18. A B C D 19. A B C D 20. A B C D |
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LESSON EVALUATION
Please indicate the date you completed this exam __________________________________ How much time did it take you to complete the lesson? ____ hours ____ minutes How well did this lesson achieve its educational objectives? ____ Very well ____Well ____ Somewhat ____ Not at all What overall grade would you assign this lesson? A B C D Degree ____________ Additional comments and suggestions for future exams: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ |