REGISTRATION FORM

Registration Instructions:

This site does not offer online registration. However, you may complete this form on your computer, print it out, and fax or mail to the address below.

1.

Enter your information in the spaces provided below.
The tab key will move you from cell to cell.

2.

Print pages.

3.

Make check out for $959 payable to University of New England
or fill out the credit card information below.

4.

Fax or Mail completed forms and check to:
University of New England,
Department of Continuing Medical
and Professional Education,
Stella Maris Hall #317,
11 Hills Beach Rd, Biddeford, ME 04005
Fax: 207-602-5957

I am registering for

Summer Institute (June 2-5, 2013)

Last name

First name

Organization

Title/Position

Work Mailing Address

City

State Zip

Work Phone

Fax

Email

How did you find out about the Institute?

Please check here if you do NOT want us to put your name and contact information above on a list for participants only

PAYMENT: Institute tuition: $959