REGISTRATION FORM
Use this form to register for the Five-hour Workshop for Mental Health Professionals
Back
From the War:
Psychological Needs of the Returning Combat Veteran
My
Contact Information (please use one form per person)
Name,
Degree:
Occupation:
Street Address:
City, State, Zip:
Home Phone:
Work Phone:
Fax:
Email:
Workshop
Fee
Workshop
(includes 5 hours CME, CEU or letter of attendance): $100
Donor Reception: Additional $100 tax-deductible donation per person
Form
of Payment
_____
Enclosed check payable to the NC Psychoanalytic Foundation.
_____ Credit 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
27.
After deadline, call (919) 847-2323 to check space availability.
Please
Mail Form and Check to