REGISTRATION FORM
North Carolina Psychoanalytic Foundation

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Healing the Soul:
Why Medication For Anxiety And Depression Is Not Enough

My Contact Information:
Name, Degree
Occupation
Street Address
City, State, Zip
Home Phone
Work Phone
Fax
Email

Fee:
Tickets: $15 for lecture ($20 at the door)
Supporter: $100 (1 ticket to lecture & reception)
Patron: $500 (4 tickets to lecture & reception)
Benefactor: $1,000 (6 tickets to lecture & reception)
I wish to purchase ___ lecture ticket(s).
Enclosed is a check for $_________.

Deadline:
To guarantee space at lecture or reception, registration must be received by February 21.
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:
North Carolina Psychoanalytic Foundation
7474 Creedmoor Road #107
Raleigh, NC 27613

Space is Limited          Register Early

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