"Changing Tides in Medicine" Seminar Registration Information & Payment By Credit Card

This form must be completed when registering via the Internet and paying by credit card ONLY! NOTE: Do not use punctuation when entering information or the form will not be accepted.

1. First Name
2. Last Name
3. Credentials
4. Street Address
5. City
6. State
7. Zip Code
8. Phone (Home or Cell)
9. Email Address
10. AARC Number (if not a member, enter NON MEMBER)
11. Name of Work Place or School
12. How Did You Hear About This Event?

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