5th COMPREHENSIVE  REVIEW OF PSYCHIATRY
Friday to Sunday, July 10-12, 2009
Conference Center
Niagara Falls, New York

Registration Form   # …….
 
Name ______________________________________

Address _____________________________________


City _____________________State ____ Zip _______


Telephone (____) _________ Fax (____) __________


E-mail _______________________________________
?  MD  ?  RN  ?  PhD  ?  Pharm 
?  SW  ?  Other   ____________________                 


Registration Fee
$200.00 for 3 days (includes breakfast & lunch)
$100.00 for one day (specify day)
Friday (   )   Saturday (   )   Sunday (   )
   
Easy Ways to Register

( PHONE (716) 898-4870
2  FAX (716) 898-5332
+ MAIL this form with your payment to:

Beverlie Battista
UB Department of Psychiatry                                                                                        Erie County Medical Center
462 Grider Street 
Buffalo, New York  14215

Please make checks payable to:
University Psychiatric Practice, Inc.
Or charge my:
q VISA q MasterCard q AMEX q Discover


Card # _____________________________


Expiration Date ___/___


Signature ___________________________