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2nd Annual Essentials in Primary Care Winter Conference

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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

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