SEAK,
Inc. Falmouth, August 2002 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:
___
Malpractice Survival Training For Physicians ($695) Cape Cod August 1-2, 2002
___How To Be A Successful Independent
Medical Examiner ($695) Cape Cod
August 1-2, 2002
___Negotiating Skills For Physicians ($695) Cape Cod August 1-2, 2002
___Business School For Physicians ($695) Cape Cod August 3-4, 2002
___How To Be An Effective Medical Witness ($695) Cape Cod August 3-4, 2002
___Medical Non-Fiction Writing For Physicians ($695) Cape Cod August 3-4, 2002
___Law School For Physicians ($895) Cape Cod August 5-7, 2002
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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