15th Annual Scottsdale Prostate Cancer Symposium 2010 March 4-7 2010 Camelback Inn, A JW Marriott Resort and Spa Scottsdale, Arizona

Course Registration Form

Mail to:
Diversified Conference Management, Inc.
4020 W. Phantom Horse Place • Tucson, Arizona 85658
(520) 744-6076 or (800) 458-2535   
Fax for Registrations Only: (734) 253-2679
E-mail: dcmi@comcast.net

 

Please print out the form below, fill out, and either mail to the above
address or fax back to the above fax number or register on-line.

Your Name
Specialty
Address
City, State, Zip
Telephone Number
Fax Number
E-Mail Address
Please Enter name of course you are registering for
Enclose a check (U.S. Currency Only) payable to DCMI for: Discounted Fee by February 1, 2010 $795 Physician/Physicist $550 Dosimetrist/Sonographer   Full Fee After February 1, 2010 $895 Physician/Physicist $650 Dosimetrist/Sonographer
If Paying by Credit Card:
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Expiration Date
Specify Either MasterCard VISA
Signature (if mailing or faxing in form)
I will be reserving accommodations at Cameback Inn, a JW Marriott Resort and Spa Yes No
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