CAMLT 2009 CRUISE TO HAWAII REGISTRATION FORM

 

Print Clearly.  One registrant per form only (copies acceptable).  Incomplete forms will be returned unprocessed.

 

 

Name ____________________________________________________

CLS, MT, Phleb. License/Cert. # _____________________________

 

Home Address ____________________________________________

Employer _________________________________________________

 

City, State, Zip ____________________________________________

Work Address _____________________________________________

 

Home Phone __________________________________

Work Phone ____________________________________

 

Email ________________________________________   Day Phone __________________________________

 

[   ] CAMLT MEMBER     MEMBER # _______  Do you have 20/20 Option? [     ] Yes [     ] No  Chapter Affiliation _________________________
[   ] Non-Member

 

Check the course numbers you plan to attend:

 

SESSION 1:

Tuesday, April 14, 2009 – 8:30 – 11:30 AM;  3.0 CE/Contact Hours

 

SESSION 3:

Thursday, April 16, 2009 – 8:30 – 11:30 AM;  3.0 CE/Contact Hours

090-001

[     ]

Selected Statistics in the Clinical Laboratory

090-003

[     ]

Chemistry Pot-Pourri

 

 

SESSION 2:

Wednesday, April 15, 2009 – 8:30 – 11:30 AM;  3.0 CE/Contact Hours

 

 

 

SESSION 4:

Friday, April 17, 2009 – 8:30 – 11:30 AM;  3.0 CE/Contact Hours

090-002

[     ]

Outcomes and the Clinical Laboratory

090-004

[     ]

Problem Solving and Decision Making

 

 

FEE SCHEDULE:

Course fees are based on the number of continuing education units.

METHOD OF PAYMENT:

 

 

Charge: [    ] VISA  [    ] MasterCard

_____ CEs     x $ _____ per CE =

$ _____

Card No: __________________________ Exp. Date: ________

                                 Members: $15.00 per CE

 

Signature: _______________________________________

Non-members: $25.00 per CE

Date: _____________

 

Subtotal:

$ ______

If paying by check, make payable to: CAMLT

 

Mail Completed Form to:

CAMLT

1895 Mowry Ave., Suite #112

Fremont, CA  94538-1766

 

Returned Checks subject to a $20 fee

 

If paying by Credit Card (VISA/MasterCard only), you may fax registration form to: 510-792-3045.

Less 20/20 Group Discount:

$ ______

Total:

$ ______

 

Pre-registration Deadline: April 1, 2009