Orlando 2004 registration form

Orlando 2004 registration form

Orlando 2004 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 ($795)

November 4-5, 2004 Radisson University Hotel, Orlando, Florida

2004 IME Summit ($1,195)

November 4-5, 2004 Radisson University Hotel, Orlando, Florida

Law School for Physicians ($995)

November 5-7, 2004 Radisson University Hotel, Orlando, Florida

2004 Medical Witness Summit ($1,195)

November 6-7, 2004 Radisson University Hotel, Orlando, Florida

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