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Nephrology - CME

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April 15-20, 2007 The Westin Copley Place ~ Boston, Massachusetts<br />

NEPHROLOGY<br />

2 0 0 7<br />

Registration Form PLEASE PRINT CLEARLY<br />

FULL NAME: LAST FIRST MIDDLE INITIAL<br />

DEGREE<br />

MAILING ADDRESS: STREET<br />

CITY STATE ZIP CODE<br />

COUNTRY<br />

E-MAIL ADDRESS<br />

Please check if you wish to be excluded from receiving e-mail notices of future Harvard Medical School<br />

Department of Continuing Education programs.<br />

DAYTIME PHONE FAX NUMBER<br />

PROFESSIONAL SCHOOL ATTENDED YEAR OF GRADUATION<br />

PROFESSION<br />

PRINCIPAL SPECIALTY BOARD CERTIFIED: YES NO<br />

ORGANIZATION AFFILIATION COURSE #272938<br />

Form of Payment<br />

Please check one:<br />

Registration Fees:<br />

Tuition fee: $1289 (U.S.D.)<br />

Reduced fee for Residents* and Fellows in Training*: $900 (U.S.D.)<br />

*A letter of verification from Department Chair must accompany application for a reduced fee.<br />

CHECK IS ENCLOSED. Please make your check payable to Harvard Medical School and mail it with this<br />

registration form to: Harvard Medical School Department of Continuing Education, P.O. Box 825, Boston, MA 02117-0825<br />

BILL MY CREDIT CARD: VISA MASTERCARD<br />

CREDIT CARD NUMBER: - - - TUITION FEE: $<br />

EXPIRATION DATE: / SIGNATURE<br />

NAME AS IT APPEARS ON CARD<br />

Registrations paid by credit card may be registered online at www.cme.hms.harvard.edu, faxed to 617-384-8686, or mailed to<br />

Harvard Medical School Department of Continuing Education, P.O. Box 825, Boston, MA 02117-0825.<br />

Online registrants - add the first three characters of the source code found<br />

here. →<br />

Source Code: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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