Annual Urology Teaching Day 2013

May 23, 2013

                  □ PHY    □ PA      □ NP □ RN     □OTHER ___________________________

 ______________________________________________________________________________
 Name (Please Print)                            Title (Credentials)

       ________________________________________________________________________
       Address                                          City /State /Zip

       _________________________________________________________________________
Phone                                           E-mail (please print )

Organization/Hospital/Affiliation:_________________________________________

SPACE IS LIMITED

Mail or fax to:  Continuing Medical Education 45 Reade Place Poughkeepsie NY 12601

Fax to:  845-483-6249

E-mail to:  mpalumbo@health-quest.org