Andrea Donovan, MD - Continuing Medical Education - University of ...

25 th ANNUAL IMAGING SEMINARSeptember 30-October 2, 2011Online: http://cme.uvm.eduName (As you would like it to appear on Nametag and Certificate)Degree:q MD q DO q RT q OtherSpecialtyAddressCity State ZipPhoneEmailInitials Last 4 Digits of SSN (for CME tracking purposes)____ ____ ____ ____ ____ ____ ____Flash Drive vs. Syllabus (Choose only one)q I wish to receive a Flash Drive and will bring my laptop.q I wish to receive a typical Syllabus Binder with printed handouts.q I wish to receive both a binder and a flash drive ($15 fee applies)Registration Fee:qqqq$595 Physicians$225 Residents Proof of residency needed.$225 Technologists$100 Discount - Former UVM Residents and Fellowsq $15 Optional - Binder and flash driveq Add $75 if postmarked after August 17, 2011_______Total DuePayment Methodq Check (payable to the University of Vermont)q Visa q MasterCard q AmExCredit Card #ExpirationName as it appears on the Card (please print):Billing address of Credit Card if different from above:Mail to: UVM Continuing Medical Education128 Lakeside Avenue, Suite 100Burlington, VT 05401Phone: (802) 656-2292 Fax: (802) 656-1925