COURSE DETAILS

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Course Registration Deadline: October 11th, 2002

**Enrolment Limited to 75**

TITLE	SURNAME	FIRST NAME
ADDRESS
CITY	PROV/STATE	POSTAL CODE
DAY TELEPHONE		FAX NUMBER
EMAIL
SPECIALTY/HOSPITAL/FACILITY
AB COLLEGE REGISTRATION #

METHOD OF PAYMENT Send Cheques to: Continuing Medical Education 2J3 Walter Mackenzie Centre, University of Alberta Edmonton, Alberta T6G 2R7	VISA	MASTERCARD	CHEQUE payable to University of Alberta
For Payment by Credit Card, please phone in your information at (780)407-6346 or fax it at (780)407-1442.
Registration Fees of 25$ only if MAINCERT credits are required $25 - I require the MAINCERT credits
I will attend the Conference I will attend Dr. Olley's Retirement Dinner Pre-registration required before October 11th, 2002