Updates in Breast Health For Community Providers Registration Form

Updates in Breast Health For Community Providers

Registration Form

Live Activity: UNM Domenici Center for Health Sciences, 1001 Stanford Dr. NE, Albuquerque, NM

April 27, 2024

Please plan on completing the form in its entirety. This site cannot save your information for completion at a later date.

Prior to starting this form: Complete your UNM Tuition Remission paperwork (remember proper signatures are REQUIRED), complete your UNM PR and make a copy of your check, you will be required to upload a copy of these documents at the end of this form. If you are a Medical Student proof of status IS REQUIRED. You will be required to upload a copy of your current class schedule showing you are a full time student. *Students will not receive professional credit.

CANCELATION NOTICE: If you cannot attend, UNM CPL will refund tuition, less a $40.00 administrative fee provided it is received in writing on or before April 12, 2024. No refunds will be issued after this date or for non-attendance. Conferences are subject to cancellation. In the event this conference is cancelled, UNM CPL is not responsible for any computer/device equipment rental or other costs incurred by participants.

Contact Information

First Name*

Last Name*

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First Name, Nickname, etc... (e.g. Gary, Dr. Smith)

Credentials (i.e. MD, RN, PA, etc.)*

Provide all of your credentials. If medical student, list Medical Student.

Specialty*

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If OTHER, please provide Specialty*

Company/Institution*

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Street Address*

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State*

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Zip Code*

What type of address is this?*

Business

Home

Phone Number*

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Cell Phone*

This will ONLY be used on event days.

Email Address*

Other Information

How did you hear about the activity*

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Hear Other*

What type of CME credit do you need?*

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Do you plan to attend activity meals?*

The deadline to place a meal order has passed (4/23/24). Please note that after this date, we will not guarantee meal availability.

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Dietary Needs*

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Other Dietary Need*

Registration Fees

Registration Code - On Site*

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Payment Method

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Please select your payment method below. If you are using another payment option (Free registration, Scholarship, etc...) please select other and explain.

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You have selected to pay using Other

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CPL will contact you with further information if needed.

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Credit Card Type*

Once you have submitted this form you will be automatically directed to our TouchNet payment portal. Please enter your payment information to complete your registration. If you do not complete the payment page your conference registration is incomplete. You will receive an email from TouchNet with your payment receipt once payment is received.

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You have selected to pay using a Check, PR or Other

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You have selected UNM Tuition Remission, in the registration Code above

The Tuition Remission Program is extended to: Regular full/part-time staff, faculty (from their initial date of hire) and UNM Retirees

If this is incorrect, please change your Payment Method above.

Tuition Remission

Professional Development

Course: Updates in Breast Health

Class Day/Time: April 17, 2024

Cost:

Early Bird (Until April 4 )

MD, DO, PharmD, PhD, PhC $200.00

paying with Tuition Remission $190.00

RN, OT, PT, LPN, Np, PA, Other $100.00

paying with Tuition Remission $90.00

Residents* / Students* $40.00

Regular Rate (April 5-April 22)

MD, DO, PharmD, PhD, PhC $240.00

paying with Tuition Remission $230.00

RN, OT, PT, LPN, Np, PA, Other $140.00

paying with Tuition Remission $130.00

Residents* / Students* $40.00

Onsite Rate (April 23- April 27)

MD, DO, PharmD, PhD, PhC $265.00

paying with Tuition Remission $255.00

RN, OT, PT, LPN, Np, PA, Other $165.00

paying with Tuition Remission $155.00

Residents* / Students* $40.00

Information regarding Tuition Rates and the Taxability of Tuition Remission my be viewed at: http://bursar.unm.edu/index.html

Supervisor Approval*

Supervisory approval is required if any of the following apply:

A credit course taken during the employee's regular work schedule (approval is to authorize the absence from work and to approve an alternative work schedule): or
A non-credit professional development course taken during the employee's work schedule that is related to the employee's job or a UNM job to which the employee may reasonable aspire (approval is to authorize absence from work and approve an alternative work schedule): or
A non- credit health and fitness course taken during the employee's work schedule (approval is to authorize the absence from work and to approve an alternative work schedule).

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How will you submit your Tuition Remission Form?*

I will upload my form now with the appropriate signatures required.

I will email CPL at HSC-CPL@salud.unm.edu, my completed Tuition Remission form.

What is your UNM Banner ID?*

Employment Status*

Faculty/Staff

Retiree

Work Number*

Phone

Employee Certification

Please check the following statements, to indicate you acknowledge each.

Information regarding Tuition Rates and the Taxability of Tuition Remission my be viewed at: http://bursar.unm.edu/index.html

I acknowledge that I have reviewed UAP 3700, “Education Benefits” and certify this request for Tuition Remission Benefit is within the maximum allowable benefit per semester as provided in the Policy.*

I understand that I am responsible to repay all costs that exceed the maximum allowable benefit.*

I acknowledge the University will bill me for any excess tuition costs that have been paid. If the bill is not paid, UNM may collect any excess through payroll deductions*

I acknowledge that the amount of tuition benefits for certain courses are considered taxable under current published IRS regulations. I understand that any taxable tuition benefit I receive will be added to my wages as taxable income and will be subject to income tax withholding.*

Additionally, I understand that if the amount of tuition benefits I receive during the calendar year exceeds the published IRS maximum amount, the amount in excess of the IRS maximum will be added to my wages as taxable income and will be subject to income tax withholding.*

File Upload*

If you are paying by check, a copy of the check MUST be uploaded here. Checks MUST be received by UNM CPL within 5 business days of completing this registration site. Please make checks payable to: UNM CPL 1 University of New Mexico MSC09 5370 Albuquerque, NM 87131-0001

If you are paying by UNM PR, a copy of the PR MUST be uploaded here.

If you are a Student please upload your current fulltime student schedule here.

Upload your signed Tuition Remission Form here.

*This is a required field and you will not be able to finish this form unless you upload something.

If you are unable to upload the necessary information listed above please contact us at HSC-CPL@salud.unm.edu or 505-272-5166 for assistance.

Drag and drop files here or

Once you have submitted this form you will be automatically directed to our TouchNet payment portal.

Please make sure you EXIT the Touchnet page so your registration enters our system.

*Your conference registration is not complete until we have received your payment method.

Once you have submitted this form you will be automatically directed to our TouchNet payment portal.

You MUST complete your payment in this portal.

*Your conference registration is not complete until we have received your payment method.

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