SCCO CE Online Registration Form

Course Registration Form (Vision West members)
	*( Required fields)**
* First Name
* Last Name
(First & last name as it appears on your optometric license)
* Address
* City
* State
* Zip
* Phone
Fax
* Email
* Re-Enter Email

* License #
* State of License
* Full Vision West Member Account #	(Example: 10-0000001)
Name of Course (s)
Total Payment Due	$