Fax Registration for SEAK Falmouth 2005

Fax Registration for SEAK Falmouth 2005

SEAK, Inc. Cape Cod, August 2005 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. P.O. Box 729, Falmouth, MA 02541

priority code: web

Please register me for:

___How to Start and Build a Successful Expert Witness Practice ($495) Cape Cod August 17, 2005
___How to be An Effective Medical Witness ($995) Cape Cod August 18-19, 2005
___Medical Malpractice Survival Training ($995) Cape Cod August 18-19, 2005
___2005 IME Summit ($1,195) Cape Cod August 20-21, 2005
___Non-Clinical Careers for Physicians ($1,195) Cape Cod August 20-21, 2005
___Law School for Physicians ($1,195) Cape Cod August 22-24, 2005

___________Amount Enclosed

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