UTMB
DERMATOPATHOLOGY REVIEW
COURSE
April 26-27, 2008
Registration
Fee:
Residents
□ $140 early registration □
$165 after April 11 and on site
In-Practice □ $165
early registration □ $190 after
April 11 and on site
Name
___________________________________________________
Business
Address __________________________________________Institution
_______________________________________________________
Street
Specialty
________________________________________________
Daytime
Phone ____________________________________________
Email
Address _______________________@____________________
Payment
enclosed _$________________________________________
Credit
Card Info __________________________ Number VISA/MC/AE
____________________
Exp __________________________CVC Code
__________________________________________________Cardholder’s
Signature
Signature
of Residency Program Director___________________________________
Make
Checks payable to Department of
Dermatology
CONTACT INFORMATION:
Kimberly J Cooper
UTMB
Department of Dermatology
4.112 McCullough Bldg
409 772-1911 phone
409 772 1943 fax
kjcooper@utmb.edu
Refund
and Cancellation Policy:
A
full refund will be issued if written notice of cancellation is received by
April 11th. After April 11th, fee will
be refunded minus a $20 administrative fee.
NO
REFUNDS AFTER April 20, 2008