neW York
neW York
neW York
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“Prostate cancer: Predictive Models for Decision Making”,<br />
new <strong>York</strong>, april 7-9, 2011<br />
Please fill in this form in Block caPitals and send to:<br />
Peter Brodhead – CME Office - Memorial Sloan-Kettering Cancer Center<br />
633 Third Avenue 12th Floor, New <strong>York</strong>, NY 10017, USA<br />
online registration aVailaBle at www.mskcc.org/cme<br />
ParticiPant's Details<br />
Last Name First Name<br />
Medical Degree Specialization<br />
Institutional Affiliation<br />
Department<br />
Personal Address<br />
Street<br />
Job Address<br />
Zip Code City Country<br />
Tel<br />
Email<br />
Fax Mobile<br />
the number of seats at the conference venue is limited and therefore, early registration is<br />
strongly recommended. onsite registration will be accommodated according to availability<br />
but no guarantees can be made.<br />
Payment must accompany the registration form and be processed by March 7, 2011<br />
(after this date, registration will only be available on site).<br />
The registration fee covers admission to the conference, a copy of the program book, coffee and lunch throughout the<br />
conference as indicated in the program.<br />
PaYMent Details<br />
registration ForM<br />
registration Fees<br />
earlY rate (before MarcH 7, 2011) 500 $<br />
late rate anD on site 700 $<br />
trainees anD stUDents 250 $ *<br />
(* with letter of introduction from program director)<br />
creDit carD: Visa/Mastercard American Express<br />
Card No / / Expiration date /<br />
Card holder’s name in CAPITAL LETTERS<br />
Card holder’s signature<br />
cheque payable to “Memorial sloan-kettering cancer center Prostate cancer course”<br />
(enclose cheque)
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