Second Annual Course in

 

Evidence Based Preventive Medicine

 

 

Monday September 10 - Friday September 14, 2001

 

 

 

Salvatore Maugieri Foundation

Pavia, Italy

 

 

 

Registration Form

Name (include degrees):              __________________        _____________________

Affiliation:                                         __________________

Specialty:                                         __________________

Address:                                           __________________

                                                            __________________

                                                            __________________

Tel. (include country code):        __________________

Fax:                                                    __________________

Email:                                                __________________

Category (please circle):                          A         B

 

Please fax your registration form or email your information to:

 

 

Email (click): mailto:hjs@buffalo.edu

 

Payment information:

q       Check

q       Credit Card  _____________ _________________________    ___/___

(Type)                     (Number)                                               (Expiration Date)