APIC Seminar - Registration Form


P R I N T T H I S P A G E
REGISTRATION FORM The IP’s Challenge: Dealing with Age Old Issues in the New Millennium August 5, 2011 Methodist Dallas Medical Center - Hitt Auditorium 1441 N. Beckley - Dallas, TX 75203 Instructions: 1) Complete the form ~ 2) Make check payable to APIC-DFW ~ 3) Mail form and check to Sylvia Trevino, APIC-DFW Treasurer 826 Torrey Pines Lane Garland, TX 75044

Name (with credentials)

Address

City / State / Zip

Preferred Phone (Indicate DAY or EVENING)

E-mail Address (For registration confirmation)

Facility

REGISTRATION DEADLINE: AUGUST 1, 2011 $105.00 FOR ALL REGISTRATIONS POSTMARKED/RECEIVED AFTER August 1, 2011 NO REFUND FOR CANCELLATION AFTER August 1, 2011
_____$80.00 APIC Member(APIC ID# _________________) _____$105.00 Non-Member _____$105.00 Late Registration (Postmarked after August 1, 2011)