CME JAX Brochure - Changing Trends - MC8100-28 - Mayo Clinic

REGISTRATION FORM
2007J508
Advances and Changing Trends in Medicine – Update 2007
August 6 – August 8, 2007
Loews Miami Beach Hotel, Miami Beach, Florida
Register online: www.mayo.edu/cme/aug2007.html
or mail/fax form and payment to:
Mayo School of Continuing Medical Education Telephone: 800-462-9633
4500 San Pablo Road Office: 904-953-2481
Jacksonville, FL 32224 Fax: 904-953-2954
ATTN: Registrar ACT07
Email: cme-jax@mayo.edu
Please print or type all information. You may reproduce this form for multiple registrations or
register online.
First Name
Degree
M.I.
Last Name
q M.D. q D.O. q P.A. q N.P. q R.N. q Other
Institution
Medical Specialty
Email
Mailing Address
City State Zip
Country
Telephone
Business Telephone
Int'l Telephone (Country Code) (City Code) (Phone)
Fax
q Check here if you have any special accommodations or dietary needs.
Please indicate your needs here:
Requested credit: q AMA/Category 1 q AAFP q AOA q Florida Nurse
Reception - Monday, August 6, 2007 • 7:00pm – 8:00pm
Will you be attending the Welcome Dessert Reception? q Yes q No # of guests
Will you require headsets for Simultaneous English to Spanish Translation? q Yes
Registration and Payment (U.S. Funds only)
Registration Fee:
Physicians/Scientists $550 $
Residents*, Physician Assistants, and Nurse Practitioners $425 $
*Resident status documentation required
Total Payment Enclosed: $
Payment Method:
q Check Enclosed (make checks payable to Mayo Clinic Education)
q Credit Card: q Visa q MasterCard
Card Number:
Expires (Mo/Yr):
q No
Will you be applying for the International Registration Scholarship? q Yes q No
To obtain additional information or a scholarship application please email
cme-jax@mayo.edu and indicate “Scholarship” in the Subject line.
Signature
Date