MainGate Continuing Education 

                               The Gateway to Chiropractic CE Credits

Phone: 843 215-6332

Fax: 843 215-6631

maingatece@gmail.com

Printable Form


Registration Form

Please print and complete this form, then fax to 843 215-6631 or email to maingatece@gmail.com

Doctor's Name:_________________________________________________

E-mail:_______________________________Phone:(_____)_____________

Seminar Date:________________Location:__________________________

Course Name:__________________________________________________


Payment Method

If paying by check, please mail a copy of this registration form and that check to:

MainGate CE

442 Coral Harbor Drive, SC 29588

(  ) Paying by Check. Check #__________________________________

Credit Card: (  ) Visa  (  ) MC  (  ) Discover (  ) AmX 

Number:___________________________________________________

Expiration Date:_____________________Amount: $________________

Billing Address of Card:________________________________________

City:____________________________State:_____ Zip:_____________

Signature:__________________________________________________

Please Note: Cancellations requested 7 days prior to the seminar will receive a refund, less a $50 administrative fee. No refund will be granted after this date. MainGate CE is not responsible for any expenses incurred by registrants do to program adjustments or cancellations. Confirm seminar status before on-site registration.