2013 GI Teaching Day
Advance
Registration Form
□ PHY $145.00
□ PA $145.00
□ NP $145.00
□ RN $125.00
□OTHER $125.00___________________________
______________________________________________________________________________
Name (Please Print) Title (Credentials)
________________________________________________________________________
Address City /State /Zip
_________________________________________________________________________
Phone E-mail (please print )
Organization/Hospital/Affiliation:_________________________________________
Payment Information
Fee includes, attendees conference materials, syllabus, and meal
SPACE IS LIMITED
Payment Methods
□ Check enclosed for $________
Please make check payable to Vassar Brothers Medical Center CME
or
□ *HQ RTA Submitted
or
□ *HQ Transfer from Account #_______________
-or-
Please charge my
□ MasterCard □ Visa □ American Express □ Discover
CARD #________________________________________________
Exp Date:_____________________ Signature:__________________
NO REFUNDS after Sept 15. We strongly encourage advance registration.
Mail to: VBMC-CME 45 Reade Place Poughkeepsie NY 12601
Fax to: 845-483-6249
