Fax Registration for SEAK San Diego 2001

Fax Registration for SEAK San Diego 2001

SEAK, Inc. San Diego, March 2001 REGISTRATION FORM

To register, call SEAK, Inc. at 508-457-1111, or Print this form and complete the requested information (neatly, please),
and FAX to SEAK, Inc. at 508-540-8304, with credit card information.
Or mail with credit card information or check to: SEAK, Inc. PO Box 729, Falmouth, MA 02541

priority code: net

Please register me for:
___ 10 Annual Workers’ Compensation and Occupational Medicine Seminar ($595: San Diego, March 28-30, 2001)
___ Delayed Recovery: What Works ($295: San Diego, March 27, 2001)
___ Law School for Occupation Health Professionals ($295: San Diego, March 27, 2001)

I would like to apply for the following credits (Please check as many as are applicable):

__Attorney __Case Manager __Chiropractor __Disability Specialist __MD/DO __ Occupational Health Nurse __ Psychologist __ Qualified Medical Evaluator __ Rehabilitation Counselor __ Rehabilitation Nurse

Check Enclosed (made out to SEAK, Inc.)

Credit Card Billing Type of card: ___Visa ___MC ___AE

Card No.

Exp. Date:

Signature

Please print or type all information. Use abbreviations as necessary.

Name                                                                                                                                                              Title

Name of Organization

Address

City                                                                           State                        Zip

Phone (Area Code/Number)                                       Fax

E-Mail

Specialty

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SEAK, Inc. FAX (508) 540-8304