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31 ASHI Quarterly Third Quarter 2015 Processing Fee: ASHI Member – no fee Nonmember – $30 Payment is due with submission of answer sheet. Make check or money order payable to ASHI (U.S. currency only). Do not send cash. No refund under any circumstances. Please allow six weeks following the submission deadline for paper processing. Individuals paying by credit card may fax the answer sheet to 856-439-0525. Please check one: Enclosed is check #______________ (payable to ASHI) Charge to the following card: MasterCard (16 digits) Visa (13 or 16 digits) Amex Card Number________________________________ Exp. Date _________ Signature _____________________________________________________ Print Cardholder's Name _________________________________________ ASHI Quarterly Continuing Education Quiz Answer Sheet Please print clearly in black ballpoint pen First Name Institution Address Address City State/Province Zip Code/Postal Code Country ASHI Membership Number (MUST complete if requesting fee waiver) M I Last Name Instructions: Mark your answers clearly by filling in the correct answer, like this , not like this 3.0 credit/ contact hours or 0.45 Continuing Education Credits (CECs) earned withpassing score (70%). Please use black ballpoint pen 1 A B C D E 2 A B C D E 3 A B C D E 4 A B C D E 5 A B C D E 6 A B C D E 7 A B C D E 8 A B C D E 9 A B C D E 10 A B C D E For Internal Use Only Date Received: ______________________ Amount Received: ___________________ Notification Mailed: __________________ Answers to 2nd Qtr 2015 Quarterly Quiz: 1 B, 2 D, 3 E, 4 B or E, 5 D, 6 D, 7 B, 8 E, 9 D, 10 B, 11 A, 12 D, 13 C, 14 D, 15 E The quiz answer sheet will not be graded, no CE credit will be awarded, and the processing fee will be forfeited unless postmarked by: Quiz Identification Number: ABHI Program Number: CA Provider Number: FL Provider Number: December 1, 2015 39-3-2015 2015-06 0085 FL50-2203 Mail to: ASHI Executive Office ASHI CE Quiz 1120 Rte. 73, Suite 200 Mount Laurel, NJ 08054 Fax: 856-439-0525