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CONTINUING EDUCATION

GERIATRIC PSYCHIATRY IN 2006
Friday & Saturday
October 27-28, 2006
The Hilton Boston Back Bay


TUITION FEE: DOCTORAL LEVEL PROFESSIONALS-$ 325 ; ALL OTHERS-$225

DR.____ MR.____ MRS. _____ MS._____

NAME
__________________________________________________________

LAST NAME, FIRST NAME, MIDDLE INITIAL
DEGREE
__________________________________________________________

 

MAILING ADDRESS:
STREET
__________________________________________________________
CITY, STATE
__________________________________________________________
ZIP CODE
__________________________________________________________
DAYTIME PHONE
(__________)_____________________________
FAX NUMBER
(__________)_____________________________
E-MAIL ADDRESS
__________________________________________________________

 

METHOD OF PAYMENT (CHECK ONE BELOW):

CHECK IS ENCLOSED: PLEASE MAKE YOUR CHECK PAYABLE TO
      MCLEAN HOSPITAL

BILL MY CREDIT CARD THE TUITION FEE OF (CHECK ONE): $325 $225

VISA

MASTERCARD

AMERICAN EXPRESS

CREDIT CARD NUMBER
____________ ______________ ________________ ______________
EXPIRATION DATE
_________/________________________________________________
SIGNATURE
__________________________________________________________


Please mail this registration form and your payment to:

McLean Hospital
Dept. of Continuing Education
115 Mill Street
Belmont, MA 02478

OR Fax this form with credit card information to 617-855-2349.