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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) :











2015 Congdon Agenda
January 14, 2015 - Pediatrics
February 11, 2015 - Cardiology
March 11, 2015 - Pain Management & Addiction
April 8, 2015 - Hypertension
May 13, 2015 - Psychiatry
June 10, 2015 - Emergency Medicine
July 8, 2015 - Billing & Coding
August 12, 2015 - Genetics for Primary Care
September 9, 2015 - Geriatrics
October 14, 2015 - Pulmonary Medicine
November 11, 2015 - Pre-Diabetes & Obesity

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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