CEP Registration Form Participant

CEP Participant Registration

Enter your information below to register as a participant in the

CEP program. In this role, you will have full access to CEP

modules, learning materials, and certificate exam.

Participant First Name *
Participant Last Name *

Participant's Email *

Practice Name *

Phone *

Admin/Trainer Full Name *

Admin/Trainer Email Address *

How long have you worked in eyecare? *

What is your current position or job title? *

What is the highest level of education you have achieved? *

What other certifications do you have?

What do you hope to get out of this program? *

How did you hear about us? *

Are you a current BSM Connection or CPSS member? *

YesNo

I agree to receive email communication from program sponsor ATPO