2nd Annual Essentials in Primary Care Winter Conference

121 views

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
121
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

2nd Annual Essentials in Primary Care Winter Conference

  1. 1. ESSENTIALS IN PRIMARY CARE WINTER CONFERENCE At The Hilton Marco Island Resort, Marco Island, Florida February 3-7, 2014 Registration Form (FAX: TO 516-539-3555) FIRST NAME: _______________________________________________ LAST NAME: _______________________________________________ EMAIL: ___________________________________________________ (Required for confirmation, updates, etc. This will be kept confidential) ORGANIZATION/ COMPANY: __________________________________ TEL (Cell or Home): ______________________________ TEL (Work): _____________________________ TITLE: ________ ADDRESS 1: _______________________________________________ ADDRESS 2: _______________________________________________ CITY: __________________________________________ STATE/Province: _____ POSTAL CODE: _________ COUNTRY: ______________________________ SPECIALTY: _____________________________ Years Practicing: ________ Patient Population: __General/ __Children/ __Adult Men/ __Adult Women/ __Elderly How did you hear about this conference: _____________________________________ Fees:   $685.00 - Physicians $585.00 - Residents and other healthcare professionals PAYMENT METHOD: ___ CREDIT CARD (Visa/MasterCard): Card #__________________________________ Name on Card:_________________________ Expiration Date_________ Security # (on back of card) ______ Billing Address (If different from above):________________________________ ST:_________ ZIP:________ ___ CHECK Mail: Continuing Education Company, Inc. 138 Palm Coast Pkwy, NE Suite 152 Palm Coast, FL 32137-8241 Make Checks Payable to: Continuing Education Company, Inc. FAX: TO 516-539-3555 CONTINUING EDUCATION COMPANY, INC. ● 138 PALM COAST PKWY, NE ● SUITE 152 ● PALM COAST, FL 32137 TEL: 800.327.4502 ● FAX: 516.539.3555 ● eMail: Walter@CMEmeeting.org ● Web: www.CMEmeeting.org A NON-PROFIT 501 (C)(3) ORGANIZATION

×