biostat200 paymentform by h6VfBUk

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									                            Biostatistical Methods in Clinical Research I
                                              Fall 2012
                                           Application and Payment Form

First Name:                               Last Name:                              Middle Initial:

Degree(s):

Office address:



UCSF Box Number:

Daytime phone #:        (    )   -                                      Fax #:(      )    -

Email address:

Current position (eg, Resident, Fellow, Asst Prof):

Institution:

School (e.g., Medicine, Nursing, Pharmacy, Dentistry, etc):

Department (e.g. Medicine, Pediatrics, etc):

Division (e.g., Cardiology, Infectious Diseases) (if applicable):

Date of Birth:

Ethnicity:                                                              Gender:

Country of citizenship:

Program Director or Division Chief/Dept Chair:

Payment Options:
□ Enclosed is a check payable to “UC Regents” in the amount of:
        □ $1850.00 (for UC affiliated personnel)
        □ $3700.00 (for non-UC affiliated personnel)
□ Bank wire transfer (contact Patty Tan, ptan@psg.ucsf.edu, for details)
□ My Department is sponsoring me to attend the course:
Recharge to: NCA(6)_ _ _ _ _ _ Fund(5) _ _ _ _ _ DPA (6) _ _ _ _ _ _ Fund Yr (2) _ _
Account name:
Authorizing signature:
Print name of person authorizing recharge:
Campus mailbox:                                            Telephone number:
Please indicate below whether you prefer the in-person or online version of the course and whether you’d be willing to
sign up for your second choice if your first choice is not available. Note that both versions will be the same price.
Version                          First choice (check one)                   Willing to take (check all that apply)
In person                        □                                          □
Online                           □                                          □
Return to Olivia DeLeon by September 10, 2012: UCSF- Box 0560 OR 185 Berry St, Suite 5700, San Francisco,
CA 94107. Fax: (415) 514-8150 Phone: (415) 514-8231 Email: olivia@epi.ucsf.edu

								
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