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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) :











2016 Congdon Agenda
  • January 13 - Gastroenterology
  • February 10 - Cardiology
  • March 9 - Pain and Addiction
  • April 13 - Ethics and Palliative Care
  • May 11 - Urology
  • June 8 - Oncology
  • July 13 - Emergency Medicine
  • August 10 - Neurology
  • September 14 - Rheumatology
  • October 12 - Infectious Disease
  • November 9 - Diabetes
  • December 16 - (TBD) Board Review

PERSONAL INFORMATION: Please complete the form below. The information you are about to submit is secure. (Bolded fields are required.)

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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