21^st APPFP Annual Symposium: "Primary Care Update" 2008

Name:   *Title:   Specialty:

Address:

City:       State:        Zip:
Daytime Phone:      Fax:    Email:

License Number:   State where licensed :

             Credit card registrants may fax this completed form to (850) 477-8144 or use the submit button below.

                                            VISA       MASTERCARD       AMERICAN EXPRESS        

Name as it appears on card:

Card number:  Expiration Date:  Amount:$

                     *Title will be used to create your certificate, please enter correct information.
                         The fee covers the conference, syllabus, break refreshments, and lunch.

For Physicians, Podiatrists, Dentists, Chiropractors & Pharmacists:

                       Advance Registration $250
                      Postmarked after 9/6/08 and Onsite Registration $300

For Nurse Practitioners, PAs, & Allied Health Professionals:

                       Advance Registration $150
                      Postmarked after 9/6/08 and Onsite Registration $200
 

For Residents*:

                       Advance Registration $50

                       Postmarked after 9/6/08 and Onsite $100
           *Letter from director of training must accompany registration.

For Nurses, Respiratory Therapists:

                       Advance Registration $100

                       Postmarked after 9/6/08 and Onsite $150

Refund Policy: A refund minus a $50 administrative fee will be given if notification is received on or before August 13, 2008, 3:30 pm CDT. Sorry, no refunds after August 13, 2008, 3:30 pm CDT.
 

Make checks payable to MECOP and mail with completed form to:

                Medical Educational Council of Pensacola (MECOP)
                8880 University Parkway Suite C, Pensacola, Florida, 32514

Have questions? Call (850) 477-4956 or visit MECOP website at www.mecop.org

Special Accommodations
Meetings are held in barrier-free facilities. Reasonable arrangements for persons with disabilities will be made with sufficient advanced notice.