Registration - The Maresh Domov - Texas Assisted Living Education

P.O.Box 496 • Ganado, TX 77962
Tel: 361.771.5629
Fax: 361.771.2028
Email: info@assistedlivingedu.com

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Registration

Register for the course by filling out the assisted living education course registration form below. The Maresh Domov currently offers two methods of payment for the course. If you opt to pay by PayPal, registration will be instant. If you would like to pay by check or money order, you will be taken to a screen that will allow you to print this form and send with payment.

NOTE: It is essential that you provide a working email address. Login instructions will be sent to you via email. Please fill out ENTIRE form.

IF YOU ARE RETURNING TO COMPLETE YOUR ONLINE COURSE, you do not need to re-register using the form below. Simply click here to return to the login screen and enter the email address and transaction ID sent to you previously.

Required Information

*First Name:
*Last Name:
*E-mail:

Personal Information

*Name (as you want it to appear on Certificate):
*Street Address:
*Address (2nd):
*City:
*State/Province:
*Zip Code:
*Home Phone:
How did you hear about us:
The Maresh Domov currently offers two methods of payment. Please indicate your preference by selecting either option. Online payment through PayPal (requires a credit card online and gives immediate access). If you are one of over eight million PayPal users, the transaction is as simple as clicking their button on the following page and logging in. If you do not yet have a PayPal account, you can establish one in a few moments with your major credit/debit card. Signing up is free. Check or Money Order (Mail in payment along with a copy of this form. Transaction ID will be emailed to you.) Checks or money orders should be mailed to: The Maresh Domov P.O. Box 496 Ganado, TX 77962

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National Institute on Aging | Medicare | Centers for Medicaid & Medicare

The Maresh Domov was created to educate healthcare professionals in Texas, such as assisted living and residential care home managers, for Texas Standards and Licensing Requirements.

The Maresh Domov, Assisted Living Education Online
P.O.Box 496 • Ganado, TX 77962
Tel: 361.771.5629
Fax: 361.771.2028
Email: info@assistedlivingedu.com
©2009 The Maresh Domov. All rights reserved.