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Personal Information

 
= Required
   
 
= Optional
   

First Name

 

Last Name

 
Date of Birth #
   
Please select Date and Month of your Birth date

Organization

 

Email Address

(Important)

Daytime Phone

 
Evening Phone
 
Fax
 

Address1

 

Address2

 

City

 

State(or Province)

 

Zip Code

 

Country

 
Your Organization's Access Code

If this pertains to you, this code would have been given to you by your EMPLOYER to allow you free access to the site. You can find this code on any informational material at your organization.
Promotional Code
If this pertains to you, this code would have been given to you by a marketing representative of a company you do business with to allow you access to the site. The coursework is paid for by them.
Password for your Bayside Account

This is a group of 4 numbers created by you to create a secure entry to the site on future uses.

Re-enter Password
 
How did you hear about us?

Other:
 

Professional Information
If licensed please complete. If not fully licensed or only provisionally licensed as an intern please leave this section blank.

State of Licensure
License Number (PLEASE START with the letters preceding your license number (e.g. RN33345))
Renewal Date (mm/yy)

* Attention FLORIDA Licensees: You must enter your professional information above in order for your credit to be reported to the state. Additionally, the name on your account MUST MATCH the name on your license. If you are unable to correctly enter your license information, please email contactus@baysideceu.com with your license information.

 

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