Attn: Lorraine Halverson
Western University of Health Sciences
College of Allied Health Professions
309 E. Second Street/College Plaza
Pomona, CA  91766-1854
Phone: (909) 469-5390 / Fax: (909) 469-5438

CLER for Physician Assistants Course Registration Form

To register for the Physician Assistant Review Course, please
fill in the information below. When complete, fax or mail it
to the address above.
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Part 1 - Required Information

First: ____________________ M.I. ____ Last: _____________________
Address: __________________________________________ Apt: ________
City: _______________________ State: __________ Postal Code: ____
Home Phone: ___________________ Work Phone: _____________________
Fax: _______________________ E-mail Address: ____________________

Preferred User Name and Password (6 to 8 Characters each):
User Name: ________________ Password: ________________

Credit Card Number: _______________ Exp. Date: _____ Type: ______

Billing Statement Address (if different from above)
Name: ___________________________________________________________
Address: __________________________________________ Apt: ________
City: _______________________ State: ______Postal Code: _________
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Part 2 - Optional Information

Birth Date (mm/dd/yy) ________ Gender: _______
Degrees or Certificates: ________________________________________
Current Position:  _____________________ Years in Profession: ___
Career Goals: ___________________________________________________

How would you rate your computer and Internet skills?
___ Minimal   ___ Moderate   ___ Expert 

How did you hear about this program?
___ Print Advertisement	 ___ Conference (Please Specify)_________
___ Brochure             ___ Friend or Associate
___ Poster		 ___ Other (Please Specify)______________