Mailed Registration Form

INSTRUCTION
1. Print and complete this form.
    Your registration will not be processed unless all fields all filled up.
2. Mail the completed form and check, as applicable to:
    UTMB Office of Continuing Education, Attention: Loraine Terrell
    301 University Blvd., Galveston, TX 77555-0151   

 
 
     

First Name

MI Last Name
     

Degree/s

Credentials

Position
 

Name and Address of Hospital/Institution/Organization
MAILING ADDRESS:
       

Street

 City State ZIP
   

Day time Phone #

E-mail address
Type of Registration (check appropriate box) Box Fees
Early Bird (postmarked before 2/28/2013)   $325.00
Standard Registration (postmarked 2/28-3/15/2013)   $375.00
Late Registration (postmarked after 3/15/2013)   $425.00
Group rates(5 or more; postmarked before 2/28/2013).
    Call (409) 772-2116 for instruction		   $300.00
UTMB Staff, Faculty & Students discounted rate   $200.00
 

 

Make check payable to: UTMB Office of Continuing Education

 Or  Charge to your  Credit Card (circle one): 
AMEX  /     VISA    /  Master Card  /    Discover
 
   

Credit Card Number

Expiration Date
   
Print Name as it appears on Card Signature

*Cancellation Fee=$50.00. No prepaid registration will be issued for cancellations postmarked after 3/1/2013
 
 
             

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