coping10 regform by marcusjames

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									2n Annual Coping with Cancer Symposium
MCC 003 001 10
April 30-May, 1, 2010
Registration Deadline: April 16, 2010
Please Print Legibly
Last Name
First Name
Ml
UNCPID (if applicable)
□ Home ^Business
Mailing Address
City
State
Zip Code
Phone
Email
Fax
Sex QMale ^Female
Graduate of 	
DOB (mm/dd/yy)
Year Graduated
Employer
Specialty
Please check □Fellow
all that apply: □Resident
□student
□MD
□do
□PhD ONP
□pa DRN
□PharmD QOther
□RPh		
(please explain)
The above information helps us maintain yourCME Records.
REGISTRATION
Please complete a separate registration form for each person Registrations will not be processed unless
accompanied by full payment (check, Visa, or MasterCard). You may register by:
•	faxing your form, with complete credit card information, to 919-962-1664
•	mailing your form, along with a check or complete credit card information, to:
Office of CME
CB# 7321, Medical Bldg B
UNC School of Medicine
Chapel Hill NC 27599-7321
UNC CME recommends that you do not make air travel arrangements prior to receiving a receipt of payment or
confirmation. UNC CME is not responsible for any travel-re la ted costs.	
REGISTRATION FEES (please mark applicable fee)
j~l Symposium & CME Credit $100
Q Symposium without CME Credit $75
□ Saturday Only & CME Credit $75
□ Saturday Only without CME Credit $30
□ Friday Only $40
METHOD OF PAYMENT
□ Check made payable to UNC CME enclosed
Credit Card#	-	-
□ Credit Card (VISA or MasterCard ONLY)
Expiration Date	/
Signature of Cardholder
For your security, please provide us the zip code of your credit card billing address
Americans with Disabilities Act The University of Morth Carolina at Chapel Hill is committed to equality of educational
opportunity and does not d iscriminate against applicants, students, or employees on the basis of race, color, religion, sex,
national origin, age, disability, veteran s status, or sexual orientation If you require reasonable accommodations for a
disability in order to participate fully in this continuing education activity, pleaae call (919) B62-21 IS no later than April 16.
2010 or attach a note to your registration form.

								
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