Fax Registration for SEAK Hyannis 2002

Fax Registration for SEAK Hyannis 2002

SEAK, Inc. Hyannis July 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:
___Twenty-second Annual Workers' Compensation and Occupational Medicine Seminar ($595: Cape Cod, July 23-25, 2002)
___Designing Effective Return To Work Programs ($295: Cape Cod, July 22, 2002)
___OSHA's Revised Recordkeeping Rule ($295: Cape Cod, July 22, 2002)
___AMA Guides to the Evaluation of Permanent Impairment ($295: Cape Cod, July 22, 2002)
___Testifying Skills For Occupational Health Professionals ($295: Cape Cod, July 22, 2002)

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

__Attorney __Case Manager __Disability Specialist __MD/DO __ Occupational Health Nurse __ Rehabilitation Counselor

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