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