CONTINUING EDUCATION
McLean Hospital MBT Training
| Tuition Fee: $995.00 | |
| TITLE: __ Dr. __ Mr. __ Mrs. __ Ms. (please check one) | |
Full Name____________________________________________________________ |
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| Last (family name) First Middle Initial | |
Degree ____________ |
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Mailing Address ___________________________________________________________________________ ___________________________________________________________________________ |
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| Street, City, State, Postal 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 (check one): | |
| __ Visa | |
| __ MasterCard | |
| __ American Express | |
| Credit card number________________________________________________________ | |
| Expiration date __/____ | |
| Credit card holder's signature _________________________________________________ | |
| WEB-SITE: (this is a secure site) https://secure.mclean.harvard.edu/ceregistration/mbtt_2010.php |
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| MAIL: Please MAIL this registration form and your payment to: | |
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McLean Hospital Dept. of Continuing Education 115 Mill Street Belmont, MA 02478 |
| OR Fax this form with credit card information to 617-855-2349. | |
