Transforming Your Emotional Relationship With Food
My Contact Information
Name, Degree: _______________________________________________________
Occupation: _______________________________________________________
Street Address: _______________________________________________________
City, State, Zip: _______________________________________________________
Home Phone: ____________________ Work Phone: ________________________
Fax: ____________________ Email: _____________________________
Ticket Price
Tickets: $15 for lecture with advance purchase ($20 at the door). No CME/CE
credits.
Donor Reception: Additional $100 tax-deductible donation per person
Form of Payment
I wish to purchase ___ lecture ticket(s) and ___ ticket(s) to donor reception.
Total amount of payment: ____________.
_____ Enclosed check payable to the NC Psychoanalytic Foundation
_____ Credit Card, please check type of card: Visa ___ Mastercard ___
Credit Card Account Number: ______________________________________________
Expiration Date: _________________________________________________________
Name (as it appears on credit card): __________________________________________
Zip Code (of credit card billing address): ______________________________________
Signature: ______________________________________________________________
Deadline
To guarantee space at lecture or reception, registration must be received
by February 18.
After deadline, call (919) 847-2323 to check space availability.
Tickets purchased in advance will be held at the registration desk.
Please Mail Form and Check to: