2n Annual Coping with Cancer Symposiumâ¨MCC 003 001 10â¨April 30-May, 1, 2010â¨Registration Deadline: April 16, 2010 Please Print Legibly Last Name First Name Ml UNCPID (if applicable) â¡ Home ^Business Mailing Address City State Zip Code Phoneâ¨Email Fax Sex QMale ^Femaleâ¨Graduate of DOB (mm/dd/yy) Year Graduated Employer Specialty Please check â¡Fellowâ¨all that apply: â¡Residentâ¨â¡student â¡MD â¡do â¡PhD ONPâ¨â¡pa DRN â¡PharmD QOtherâ¨â¡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 unlessâ¨accompanied by full payment (check, Visa, or MasterCard). You may register by: â¢ faxing your form, with complete credit card information, to 919-962-1664 â¢ 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 orâ¨confirmation. UNC CME is not responsible for any travel-re la ted costs. REGISTRATION FEES (please mark applicable fee)â¨j~l Symposium & CME Credit $100 Q Symposium without CME Credit $75 â¡ Saturday Only & CME Credit $75 â¡ Saturday Only without CME Credit $30 â¡ Friday Only $40 METHOD OF PAYMENT â¡ Check made payable to UNC CME enclosedâ¨Credit Card# - - â¡ 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 educationalâ¨opportunity and does not d iscriminate against applicants, students, or employees on the basis of race, color, religion, sex,â¨national origin, age, disability, veteran s status, or sexual orientation If you require reasonable accommodations for aâ¨disability in order to participate fully in this continuing education activity, pleaae call (919) B62-21 IS no later than April 16.â¨2010 or attach a note to your registration form.
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