Chicago 2003 registration form

Chicago 2003 registration form

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

If you are having trouble printing this to one page, try adjusting the font size in your browser (VIEW)

SEAK, Inc. FAX (508) 540-8304