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Congdon Lecture Series - Enrollment Form

Please select the month(s) that you would like to enroll in the Congdon Lecture Series (Pre-registrations MUST be received by 11:59 p.m. Monday before Congdon lecture) :











2014 Congdon Agenda
January 8, 2014 - Gastroenterology
February 12, 2014 - Cardiology
March 12, 2014 - Addiction Medicine
April 9, 2014 - Hematology
May 14, 2014 - Orthopedic Medicine
June 11, 2014 - Women's Health
July 9, 2014 - Oncology
August 13, 2014 - Infectious Disease
September 10, 2014 - Radiology
October 8, 2014 - Dermatology
November 12, 2014 - Diabetes

I am registering as an:



Name and Degree (MD, DO, LMSW, etc):
Street Address:
City:
State:
Postal Code:
E-mail Address:
Telephone #:
 
CARDHOLDER INFORMATION:
Cardholder Name:
Billing Street Address:
Billing City:
Billing State:
Billing Postal Code:
Credit Card Number:
Expiration Date:Card Type
/
Security code: (on back of card)


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