Fax Registration for SEAK Hyannis 2006

Fax Registration for SEAK Hyannis 2006

SEAK, Inc. Hyannis July 2006
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 payment to: SEAK, Inc. PO Box 729, Falmouth, MA 02541
priority code: web

Please register me for:
MAIN CONFERENCE

___26th Annual Workers' Compensation and Occupational Medicine Seminar ($895:July 18-20, 2006)

PRECONFERENCES

___ Workers' Compensation Legal Issues and Defense Strategies ($395:July 17, 2006)
___ ADA, FMLA, and Workers' Compensation: In Depth ($395:July 17, 2006)
___ Injured and Aging Workers: Maximizing the Fit Between Worker and Work ($395:July 17, 2006)
___ Comprehensive Assessment and Treatment of Chronic Pain ($395:July 17, 2006)
___ Practical Ergonomics for Employers ($395:July 17, 2006)
___ OSHA for Occupational Health Professionals ($395:July 17, 2006)
___ Return to Work: Creating Momentum in the Work Restoration Process ($395:July 17, 2006)

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

__Attorney (LAWYERS ONLY) __Case Manager __Disability Specialist __MD/DO
__ Occupational Health Nurse __ Rehabilitation Counselor __Nurses

Payment Info
Please print or type all information. Use abbreviations as necessary.

□ I'm paying by credit card or Check Enclosed (made out to SEAK, Inc.) □
Type of card: ___Visa ___MC ___AmEx	Exp. Date:
Credit Card #:

Name

Name of Organization

Address

City State Zip

Phone Fax

E-Mail

Specialty

SEAK, Inc. FAX (508) 540-8304