ONLINE REGISTRATION - STEP 1
TODAY'S DATE
MM/DD/YYYY
 
YOUR STATUS
 
WHAT TEAM ARE YOU TRAVELING WITH?
 
 
FIRST NAME LAST NAME
 
HOME ADDRESS
 
CITY STATE ZIP
 
HOME TELEPHONE CELL PHONE FAX
 
PREFERRED EMAIL ADDRESS CONTACT
 
SECONDARY E-MAIL
 
Business Information (Place of Employment)
 
BUSINESS NAME
 
ADDRESS
 
CITY STATE ZIP
 
TELEPHONE FAX
 
Correspondence Preferences
 
INDICATE MAILING PREFERENCE
 
Passport Information
 
FULL NAME
 
DATE OF BIRTH PLACE OF BIRTH
 
PASSPORT NUMBER DATE OF ISSUE EXPIRATION DATE
 
PLACE OF ISSUE CITIZENSHIP
 
Clinical Specialty (medical personnel only)
 
MEDICAL SPECIALTY
(Plastics, CRNA, RN/OR, etc.)
 
MEDICAL LICENSE TYPE LICENSE #
 
STATE OF REGISTRATION EXPIRATION DATE
 
Education (medical personnel only)
 
PROFESSIONAL DEGREE
(Medical, Dental, ETC)
 
ISSUING INSTITUTION
 
ADDRESS
 
CITY STATE ZIP
 
1 - 3 Medical References (medical personnel only)
 
Reference 1
NAME TITLE
 
TELEPHONE E-MAIL
 
RELATIONSHIP
 
 
Reference 2
NAME TITLE
 
TELEPHONE E-MAIL
 
RELATIONSHIP
 
 
Reference 3
NAME TITLE
 
TELEPHONE E-MAIL
 
RELATIONSHIP
 
 

You're Not Done YET!
NEXT You MUST Fax or Scan to HTCNE Office:
(860-350-6634)
Current Medical License
Medical or Nursing School Diploma
CV / Resume
Delineation of Privileges
Then Download These Forms Here
Credit Card Authorization Form
Medical History Form
Release from Liability Form

Scan and email your Passport Photo Page ~ mlaw@htcne.org
DO NOT FAX YOUR PASSPORT
 (we'll only ask you to send it)

If you are unable to scan, please send it to
HTCNE
PO Box 129
New Milford, CT 06776