Advanced Pediatric Dermatology - University of Minnesota ...

REGISTRATION FORMAdvanced Pediatric DermatologyMay 14, 20103035/ltPlease Type or Print Clearly. A name badge and statement of attendance are generated from this form.NameAffiliationDepartment HOME OFFICEAddressMail StopCity State ZipOffice Telephone NumberFAXE-mailReceipts, confirmations, and driving directions are now emailed from our office. Please include your email address and print clearly.DEGREE MD DO PA NP RN OtherSPECIALTY Dermatology Family Medicine / Subspecialty Internal Medicine / Subspecialty OB/GYN / Subspecialty Pediatric / Subspecialty OtherOn or Before AfterREGISTRATION FEES April 16, 2010 April 16, 2010 Physician $160 $220 Non-Physician (NP, RN, PA, etc.) $130 $180 Mayo Clinic Faculty $130 $180 Mayo Clinic Residents Fee Waived Fee Waived Medical Industry Professional $160 $220UNIVERSITY OF MINNESOTA (U of M employees must have employee ID#) Adjunct Faculty $130 $180 UM/UMP Non-Physician (RN) Fee Waived Fee Waived UM/UMP Non-Physician (NP, PA) $100 $160 Full-Time Faculty Fee Waived Fee Waived Resident / Fellow Fee Waived Fee WaivedSpecial NeedsSpecial needs such as dietary restrictions should be indicated in advance; requests cannot always be honored on site.PAYMENT METHOD Check (payable to University of Minnesota) VISA MasterCard American ExpressCardholder NameCard NumberSignatureYou may choose ONE of the following methods toregister for this conference:ONLINE: Go to cmecourses.umn.eduCALL: (612) 626-7600 or (800) 776-8636FAX: (612) 626-7766TO REGISTERExpiration DateMAIL: Pediatric DermatologyOffice of Continuing Medical EducationUniversity of MinnesotaUniversity Park Plaza, Suite 6012829 University Avenue SEMinneapolis, MN 55414