(Pre-paid registration is required)

The Ethics of Bioethics & The Annual Richard T. Beebe Professor of Medicine Lecture
April 7-9, 2005

Download Registration Form in PDF

Please type or print clearly and register one person per form.

Name and Degree

(as to appear on conference information, two degrees only)

CME Tracking Number
--

Membership
ASBH
Bioethics Consortium
Staff: AMC/Straton
Staff: GCUU/Union

Specialty

Organization

Department

Office Address

City

State

Zip

Email

Home Address

City

State

Zip

Send confirmation to my:
Office address  Home Address

Please check all that apply:
I will attend the Beebe Lecture on Thursday, April 7. (no charge)
I will attend the Beebe Reception on Thursday, April 7. (no charge)
I will attend the Ethics of Bioethics Conference on Friday & Saturday, April 8-9 (full tuition required)
I will attend the Ethics of Bioethics Conference on Friday, April 8. (one-day tuition required)
I will attend the Ethics of Bioethics Conference on Saturday, April 9. (one-day tuition required)

Please check method of payment:
My check for $ , payable to Albany Medical College is enclosed.

Please charge my credit card for the amount of $

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Name as it appears on credit card


Signature

_________________________________________

Method of Registration: Fax or Mail

Fax: Only registrations paid with a credit card will be accepted by fax at (518) 262-5679. This is a secure fax.

Mail this form with payment to:

Office of Continuing Medical Education, Ethics Symposium, Mail Code 1, Albany Medical College, 47 New Scotland Avenue, Albany, NY 12208-3479