3rd annual pbrn convocation october 22, 2011 · 10/22/2011 · 2011 registration form 3rd annual...
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2011 Registration form3rd Annual PBRN Convocation
October 22, 2011PlEASE PRINT
Name:______________________________________________________________________________________________
Credentials: MD DDS DO RN PA PhD PHarmD Other
Affiliation: Network Member Faculty Clinician Student Resident TAB Member
Network Affiliation: STARNet RRNet South Texas Psychiatry VA Mental Health PRENSA
STOHN Other:___________________________________________________________
Specialty:___________________________________________________________________________________________
* Practice Site: Private Practice FqHC HPSA RHC MUA NHSC Hospital Based
Organization/Practice
Name: ______________________________________________________________________________
Address: ______________________________________________________________________________
City____________________________ State _______ Zip_______ County________________
E-Mail: ______________________________________________________________________________
Telephone: _______________________________ FAX __________________________________________
* Age: under 20 20-29 30-39 40-49 50-59 60 & over * Gender: M F
* Ethnicity: Caucasian African American Hispanic Asian Other _____________________
*Required for grant #D54HP16444
Registration Fee: $50.00 Payment method: Check Credit Card Bill Me
Registration Methods
Email: [email protected] (scan and email or fill out electronically and click the submit button)
By mail (include registration form with your check or credit card information)
UT Health Science Center SA PBRN Resource Center 7703 Floyd Curl Drive, MC 7728 San Antonio, TX 78220-3900
By fax: 210-567-7868 (include registration form with credit card information)
Credit Card Please charge $______________________ to:
VISA Mastercard Discover American Express
Card Number: ____________________________________________CSC ___________Exp. Date: ____________________
Cardholder Name:________________________________ Signature ____________________________________________
(choose all that apply)
(Make Checks payable to: South Central AHEC)
(Visa & MC last 3 numbers on the back)
“DISCOVeRINg The POweR & POTeNTIAL Of TRANSLATIONAL ReSeARCh”