Chicago 2003 REGISTRATION FORM

To register, call SEAK, Inc. at 508-457-1111, or PRINT this form, 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)
November 6-7, 2003  DePaul Center, DePaul University®

2003 IME Summit ($995)
November 6-7, 2003  DePaul Center, DePaul University®

2003 Medical Witness Summit ($995)

November 8-9, 2003  DePaul Center, DePaul University®

  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