2nd Annual Breast Cancer Symposium
Registration Form
□ PHY $125.00
□ PA $125.00
□ NP $125.00
□ RN $100.00
□OTHER $100.00___________________________
______________________________________________________________________________
Name (Please Print) Title (Credentials)
________________________________________________________________________
Address City /State /Zip
_________________________________________________________________________
Phone E-mail (please print )
Organization/Hospital/Affiliation:_________________________________________
Dinner (Guest) You are welcomed to have a guest Join you for dinner after the conference. There will be a cash bar available.
□ Yes, please add $45.00 for my dinner guest
Payment Information
Fee includes, attendees conference materials, syllabus, and meal SPACE IS LIMITED
VBMC RN <must do both>
· Submit a registration form including back up funding source (back up check/credit card will only be processed after the event if RTA is not approved or RN is a no show) to the CME department—ext. 36013
· Submit Request to Attend long form to staff development with a copy of registration
Payment Methods
□ Check enclosed for $________
Please make check payable to Mid-Hudson CME of VBMC
□ *HQ RTA Submitted
□ *HQ Transfer from Account #_______________
-or-
Please charge my
□ MasterCard □ Visa □ American Express □ Discover
CARD #________________________________________________
Exp Date:_____________________ Signature:__________________
NO REFUNDS after Sept 29. We strongly encourage advance registration.
Mail or fax to: MH-CME 45 Reade Place Poughkeepsie NY 12601
Fax to: 845-483-6249
E-mail to: momeara@health-quest.org
