Conference Registration

To register

PHONE

Call (843) 792-3777 OR 1-800-651-2926

FAX

Fax your registration form to (843) 792-1107

MAIL

Mail your registration form to:

Office of Continuing Professional Development

MUSC College of Health Professions

PO Box 250822

19 Hagood Avenue, Suite 910

Charleston, SC 29425

WEB

Complete your registration form on your computer and then fax or mail the form

Registration Form

Please Complete This Form In English

STEP 1

Complete this form on your computer

STEP 2

Print the completed form

STEP 3

FAX or MAIL the completed form (see instructions at the end of this form)

Title: Ms. Mrs. Mr. Dr.

First name:

Last name:

Suffix: Jr. Sr. II III IV Other

Credentials: List any

Social security number: (This number is used for data purposes only)

Preferred mailing address: Work Home

WORK ADDRESS:

Job title:
Organization:

Department:

Address:

City:

State: Zip: -

Country:

Phone (with area code):

Country Code (if outside U.S.):

Fax (with area code):

E-mail address:

HOME ADDRESS:

Address:
Apartment number (if applicable):

City:

State: Zip: -

Country:

Phone (with area code):

Country Code (if outside U.S.):

Fax (with area code):

E-mail address:

County of employment (if in the state of South Carolina):

Are you an alumni of the Medical University of South Carolina?

Yes No

It is the policy of the Medical University of South Carolina not to discriminate against any person on the basis of disabilities. If you feel you need services or the auxiliary aids mentioned in the Americans with Disabilities Act in order to fully participate in this meeting, please call the Office of Continuing Professional Development at (843) 792-3777 or attach a note to your registration form. Notification must be received four weeks prior to the meeting.

Registration fees

Includes tuition, course materials, breakfasts, lunches, breaks, and verification of attendance.

U.S. Currency Only Please

$295 if received by 8/15/00

$125 daily. Please Specify day.

Friday Saturday Sunday

Method of payment
Check enclosed (please make payable to "MUSC")

Amount of check:

Please charge to my VISA MasterCard

Amount to be charged:
Account number:

Expiration date:

How did you hear about this program?

Brochure State Dental Newsletter

Attended previously Colleague

Other:

Now that you've completed your registration form, you may print it and either:

FAX	(843) 792-1107
MAIL	Office of Continuing Professional Development MUSC College of Health Professions PO Box 250822 19 Hagood Avenue, Suite 910 Charleston, SC 29425

You will receive a reservation confirmation.

Refunds
Your registration fee, minus a $35 administration fee, will be refunded if the cancellation request is received prior to September 1, 2000. No refunds will be made after September 1, 2000. Substitutions are welcomed. We reserve the right to cancel the program if necessary. Full registration fees will be refunded for canceled programs. The Medical University of South Carolina cannot be responsible for reimbursement of airline or other transportation fares, hotel or rental car charges, including penalties.

Questions?
Call (843) 792-3777 or 1-800-651-2926
or send us an e-mail