Please print clearly
Check one box below--
Name______________________________________________________________________
Names of additional persons in your party_________________________________________
___________________________________________________________________________
Company Name or Affiliation (if applicable)________________________________________
Mailing Address______________________________________________________________
City, State__________________________________________ Zip Code________________
Day Phone Number_________________Alternative Phone Number____________________
E-Mail Address______________________________________________________________
Fax________________________________________________________________________
Web Address (if applicable)____________________________________________________
What is your medical specialty?________________________________________________
Cost: $110 per person per day (late fee included)
Note: Social Workers pay $35 (no late fee imposed for Social Workers)
Total number of people you are registering on this form______________________________
Total amount enclosed with this registration form: $____________________
Authorized Signature___________________________________Date______________________
For additional information, please contact Margo Mishic, 330-666-0127, mjz1128@yahoo.com
Make checks payable to:
Celiac Disease Conference
Mail your Registration Form to:
Chapter 111 Celiac Sprue Association
PO Box 5280
Fairlawn, OH 44334
Faxed forms will not be accepted.
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For Convention Committee Use Only
Date Health Care Professional Form was received_____________
No. of people attending_______________
Amount remitted: $____________
Notes______________________________________________________________________
