Name _____________________________________________________________________
 Professional Title _____________________________________________________________
 Business Name & Address _____________________________________________________
 City __________________________State _____________Zip _________________________
 Office Phone (________)_______________________________________________________
 Home Address _______________________________________________________________
 City ___________________________________State ____________Zip __________________
 Home Phone (________)________________________________________________________
 Present Position ______________________________________________________________
Special Needs________________________________________________________________

PREFERRED DATES
First Choice: _____________________Second Choice: ____________________

   PLEASE SEND ME HOTEL INFORMATION

TUITION
  Georgia Physcian ($150 non-refundable registration fee)
  Georgia Non-Physician ($100 non-refundable registration fee)
  Out of State ($500 fee)
  Georgia Medical Residents ($125 non-refundable registration fee)
  Out of State Medical Residents ($250)

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 _____________________________________________________

    Please submit Application/Registration Fee To:
             Professional Course Coordinator
             Diabetes Unit
             69 Butler Street
             Atlanta, Georgia 30303
     Phone: 404-616-3722 / 3725 / 3716      FAX: 404-616-3717