SEAK, Inc. SEATTLE 2002 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 the Independent Medical Examinations:  Advanced Strategies For Success Seminar (November 2 & 3, 2002 $495.00)

OR

___Please register me for one day only:  Please choose
     ___Saturday, November 2, 2002 ($295 one day tuition)
     ___Sunday, November 3, 2002   ($295 one day tuition) 

___I am registering prior to August 14, 2002.  Please provide me with my complimentary copy of Symptom Magnification, Deception and Malingering. 

___ Please check here if you require special accommodations to fully participate.

  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