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Independent Study Medication Administration Training (IS-MAT) Payment Form

  1. I have already registered online for this training.*

  2. If you answered NO, then DO NOT complete this form. You MUST register online FIRST to reserve a seat in the training.

  3. To make the payment, mail in your check (Made out to: Grace Cole-Alston) along with the COMPLETED form to:

  4. Gisella Semorile ~ 102 Heritage Way,Suite 103 ~ PO Box 7400 ~ Leesburg, VA 20177-7400

    (Please include a copy of the Front and Back of your CPR/First Aid card and MAT-IS Part 1 Certificate.)

  5. If you are paying for others that have already registered for this training, please list:

  6. Is your check for $45.00 enclosed? (Checks made payable to Grace Cole-Alston)*

  7. Please include a copy of the Front and Back of your CPR/First Aid Card and MAT-IS Part 1 Certificate. You MUST Print this form (use the PRINT button below) and mail it with your check. to:

    Gisella Semorile ~ 102 Heritage Way,Suite 103 ~ PO Box 7400 ~ Leesburg, VA 20177-7400

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