MRI 1996 - Form

MRI 1996: Clinical Update and Advanced Applications 62736

April 9 - 13, 1996 Tuition fee: $750 (U.S.)

Please print and fill out

Full Name: Last________________________ First___________________ Middle Initial____

Title________________________________ Affiliation__________________________________

Daytime Phone (      )___________________ Fax Number (      )______________________

Street Address_____________________________________________________________________

City____________________________ State__________ Zip Code_________ Country_________

Medical School Attended (if applicable)______________________ Year of Graduation___

Specialty 1_____________________________________________ Board Certified: Yes__No__

Specialty 2_____________________________________________ Board Certified: Yes__No__

Specialty (if non-MD)_____________________________________ Degree__________________

Full payment must accompany application (check payable to Harvard Medical School).
Credit cards are not accepted.

Mail to: Harvard MED-CME, P.O. Box 825, Boston, MA 02117-0825