Annual Education Provider Registration Form

Annual Education Provider Registration Form

This form should be completed once per calendar year by each continuing education course provider. Please complete this registration form prior to submitting any course applications.
Please note: IHS processes all requests within two weeks and often sooner. Be sure to check your spam/junk folder for emails from IHS. For best results, add "ihsinfo.org" to your email provider's "whitelist."
Education Provider/Company*
Company Main Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Company Website
Education/Main Contact Person*

First NameLast Name
Education/Main Contact Title*
Education/Main Contact Phone*

Area CodePhone Number
Education/Main Contact Email*
example@example.com
Billing Contact Person*

First NameLast Name
Billing Contact Phone*

Area CodePhone Number
Billing Contact Email*
example@example.com
Please inform IHS if your billing contact changes throughout the year by emailing lmorgan@ihsinfo.org.
Agreement
Please visit this page to read the Course Approval Requirements and Guidelines Document. By registering to be an IHS Education Provider, I understand that IHS reserves the right to withdraw approved provider status at any time for failure to abide by these requirements.
Check each box to confirm agreement.*

Thoroughly read all education provider information.Abide by the Course Approval Requirements and Guidelines document.Agree to fees and payment policies.
Easy-Verify Opt-In

At times, IHS receives requests from course attendees to add a particular course to their IHS record. The attendee may provide IHS with a certificate of attendance from the course provider. Would you like IHS to accept such certificates as proof of attendance and issue the credits (Opt-In) or would you like to be contacted to verify attendance before we issue the credits (Opt-Out)? Please note: 1.This is only applicable if the attendee was not reported on the course roster. 2.Add-on fees apply regardless of which option is chosen. 3.If an attendee does not provide IHS with a certificate as proof of attendance, IHS will contact you before issuing the credits.
Would you like IHS to accept your certificates for credit without verifying the attendance with you?*

Yes, please accept certificates issued by my organization and process the credits. I understand add-on fees will still apply.No, please continue to verify all attendance with me regardless if a certificate was provided. I understand add-on fees will still apply.I would like someone to contact me to discuss my options.
Annual Registration Fee
The Annual Registration Fee is due every year (and is based on the calendar year) prior to your first course application. Payment of this fee must be submitted with the annual registration form.

Education Provider Annual Fee: $400 USD

IHS Chapter Annual Fee: $250 USD

To expedite processing the registration form, please provide a credit card to pay the annual fee. Once the registration is accepted, the credit card will be charged. IHS will send you an email with a receipt and your company's Education Provider Number.

Annual Provider Registration Fee

$400.00

IHS Chapter Annual Registration FeeFor IHS Chapters only

$250.00

Total

$0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Payment Method

VisaMastercardDiscoverAmerican Express
Name on Card

First NameLast Name
Card Number
Expiration Date
Security Code
If you are unable to pay by credit card, an invoice will be emailed to you. Please note, courses will not be approved until payment for the annual registration fee is received. For questions regarding IHS course approval, email education@ihsinfo.org.
Please verify that you are human*
Should be Empty:

Annual Education Provider Registration Form

Agreement

Easy-Verify Opt-In

Annual Registration Fee