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 REGISTRATION
ELECTROCONVULSIVE THERAPY COURSE
2009
 Name ____________________________________________________________

 Address __________________________________________________________

 City ______________________________________________________________

 State, Zip_________________________________________________________

 Office Phone (_______)_______________Fax (_______)_________________

 E-Mail Address ____________________________________________________

 Specialty/Degree ___________________________________________________

Special Needs____________________________________________________

PLEASE CHOOSE YOUR PREFERRED DATE:
 
 May 27-29, 2009
 July 15-17, 2009
 September 16-18, 2009
 October 21-23, 2009
 November 18-20, 2009
 December 16-18, 2009

TUITION:

Three day course
  $1,200 per psychiatrist
  $600 per non-physician

 Make check payable to:
     EMORY UNIVERSITY SCHOOL OF MEDICINE
Or pay by credit card (Complete form below.)
 
Master Card Visa  Discover
 
 Expiration Date_________________________________________________ 
 Card Number  __________________________________________________ 
 Name_________________________________________________________ 
                                                    (as it appears on card) 
  Signature _____________________________________________________
Print form and mail or fax to:
    CONTINUING MEDICAL EDUCATION
    Emory University School of Medicine
    1462 Clifton Road, N.E., Suite 276
    Atlanta, Georgia 30322
    Phone:(404) 727-5695   Fax:(404) 727-5667   Toll Free Phone:(888) 727-5695
    E-Mail Address:cme@emory.edu