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October 14, 2004 • Jordan Hall Conference Center • University of Virginia , Charlottesville , VA
NOTE:
*Payment is required to accompany the registration form. You will receive written confirmation upon receipt of your payment.
*Institutional checks and purchase order payments must be received at least 14 days prior to the scheduled CME activity. If payment is not received by the deadline, you will NOT be registered for the conference.
First Name________________ M.I. ____ Last Name __________________
Credentials (M.D., D.O., etc.) _____
Credit Eligibility (please select one below)
AMA PRA Category 1 CEU (non-physician health care professionals)
Record of attendance only (residents and non health care professionals)
Affiliation__________________ Specialty ______________
Primary Address – this is home work
Street _____________________________________
City _______________ State____ Zip_____________
Telephone________________Fax _________________
Email _______________________________________
(note: all confirmations will be sent via email)
Do you require special assistance because of a handicap or disability, or have any dietary restrictions? If so, please describe:____________________________
Vegetarian
Please select one below:
I’m a University of Virginia Physician (salary paid by UVA)
I’m a University of Virginia non – physician (salary paid by UVA)
I’m a physician who is NOT employed by UVA
I’m a non-physician who is NOT employed by UVA
Registration fee:
___ $195 for all participants
Please make checks payable to:
Dean’s Office - UVa CME,
Or payment may be charged to
____VISA or _____ MasterCard (Sorry, we only accept these two cards)
Card Number _________________________________
Expiration Date _______________________________
Signature ___________________________________
Please return the registration form and fee by Friday, September 3rd to:
INSERT TITLE HERE
Bebe Moore, Registrar
Office of Continuing Medical Education
University of Virginia Health System
PO Box 800711
Charlottesville , VA 22908-0711
FAX: 434-243-6393
www.cmevillage.com
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