Annual Oncology Teaching Day 2013

June 20, 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

FEE:  $50.00

Full Time Undergraduate Nursing Students

(Nursing students should submit copy of student ID)

$25.00

Fee includes Continental Breakfast, Lunch & Course Materials

□I AM A MEMBER OF THE VBMC NURSING STAFF AN RTA HAS BEEN SUBMITTED

□HQ ACCOUNT # FOR EDUCATION (FOR NON-NURSING DEPARTMENTS __________________________________________

 □Please Charge my credit card #__________________________________________________exp date______________

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