APIC Seminar - Registration Form


P R I N T T H I S P A G E
REGISTRATION FORM Languages of the IP: Communicating with Diverse Groups August 13, 2010 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 6, 2010 $100.00 FOR ALL REGISTRATIONS POSTMARKED AFTER August 6, 2010 NO REFUND FOR CANCELLATION AFTER August 6, 2010
_____$75.00 APIC Member(APIC ID# _________________) _____$100.00 Non-Member _____$100.00 Late Registration (Postmarked after August 6, 2009)