CONTINUING EDUCATION

REGISTRATION FORM ADDICTIONS IN 2010

April 30–May 1, 2010
Doctoral Level Professionals: $395 (USD) Other Professionals and Trainees: $325 (USD) Register online at: www.cme.hms.harvard.edu/courses/addictions2010
TITLE: __ Dr. __ Mr. __ Mrs. __ Ms. (please check one)

Full Name____________________________________________________________
Last (family name), First, Middle Initial
Degree ____________

Mailing Address ___________________________________________________________________________ ___________________________________________________________________________
Street, City, State, Postal Code

Daytime Phone	(__________)________________________

Fax Number	(__________)________________________

E-mail Address	___________________________________________________________________________

___ Please check if you wish to be excluded from receiving email notices of future HMSDCE programs. REGISTRATION FORM ADDICTIONS IN 2010 (Class # 3024353)

Professional School Attended _________________________________
Profession _______________________________Year of Graduation ___________
Principal Specialty ____________________________________
Board Certified? Yes____ No ____
Organization Affiliation _________________________

__ Check is enclosed. Please make your check payable to Harvard Medical School and mail it with this registration form to: Harvard Medical School Department of Continuing Education, P.O. Box 825 Boston, MA 02117-0825

Registrations paid by credit card may be made at: www.cme.hms.harvard.edu/courses/addictions2010 Please note: telephone registrations are not accepted.
Online registrants - To ensure proper registration, please add the first three characters of the source code found here: Source Code: A B C D E F X Z