22^nd APPFP Annual Symposium: "Primary Care Update" 2009

To ensure your place at the conference, this fee, accompanied by the seminar registration form,

should be returned by September 5, 2009.

Name:   *Title:   Specialty:

Address:

City:       State:        Zip:
Daytime Phone:      Fax:    Email:

License Number:   State where licensed :

             Credit card registrants may fax this completed form to (850) 477-8144 or use the submit button below.

                                            VISA       MASTERCARD       AMERICAN EXPRESS        

Name as it appears on card:

Card number:  Expiration Date:  Amount:$

                     *Title will be used to create your certificate, please enter correct information.
The seminar registration fee includes the conference and syllabus as well as breakfast, break refreshments and lunch.

For Physicians, Podiatrists:
   
                      Advance Registration $250
                      Postmarked after 9/5/09 and Onsite Registration $300

For Nurse Practitioners, PAs, & Allied Health Professionals:

                      Advance Registration $150
                      Postmarked after 9/5/09 and Onsite Registration $200
 

For Residents*:

                      Advance Registration $50

                       Postmarked after 9/5/09 and Onsite $100
           *Letter from director of training must accompany registration.

For Nurses, Respiratory Therapists:
   
                      Advance Registration $100

                       Postmarked after 9/5/09 and Onsite $150

Refund Policy: A refund minus a $50 administrative fee will be given if notification is received on or before August 12, 2009, 3:30 pm CDT. Sorry, no refunds after August 12, 2009, 3:30 pm CDT.
 

Make checks payable to MECOP and mail with completed form to:

                Medical Educational Council of Pensacola (MECOP)
                8880 University Parkway Suite C, Pensacola, Florida, 32514

Have questions? Call (850) 477-4956 or visit MECOP website at www.mecop.org

Special Accommodations
Meetings are held in barrier-free facilities. Reasonable arrangements for persons with disabilities will be made with sufficient advanced notice.