UNC Cardiac Electrophysiology Symposium: Practical Approaches to Patient Management March 20, 2010 Registration Deadline: March 12, 2010 MME 012 001 10w Please Print Legibly Last Name _________________________ First Name __________________ MI __ UNC PID (if applicable) __ __ __ __ __ __ __ __ __ Mailing Address Home Business _____________________________________________________________________ City _____________________________ State ____ Zip Code __ __ __ __ __ Phone ___________________ Fax __________________________ Email ______________________________________________________________ Sex Male Female DOB (mm/dd/yy) ________________ Graduate of ________________________ Year Graduated _________________ Employer ________________________ Specialty _______________________ Please check Fellow MD PhD NP PharmD Other all that apply: Resident DO PA RN RPh ____________ Student (please explain) The above information helps us maintain your CME Records. REGISTRATION Please complete a separate registration form for each person. Registrations will not be processed unless accompanied by full payment (check, Visa, or MasterCard). You may register by:  faxing your form, with complete credit card information, to 919-962-1664  mailing your form, along with a check or complete credit card information, to: Office of CME CB# 7321, Medical Bldg B UNC School of Medicine Chapel Hill NC 27599-7321 UNC CME recommends that you do not make air travel arrangements prior to receiving a receipt of payment or confirmation. UNC CME is not responsible for any travel-related costs. REGISTRATION FEES (please mark applicable fee) Registration is fee waived with completed registration form which must be returned by deadline March 12, 2010 MD & DO Onsite $25.00 Other Health Professionals Onsite $15.00 UNC Faculty and Staff – Fee Waived with completed registration form Americans with Disabilities Act The University of North Carolina at Chapel Hill is committed to equality of educational opportunity and does not discriminate against applicants, students, or employees on the basis of race, color, religion, sex, national origin, age, disability, veteran’s status, or sexual orientation. If you require reasonable accommodations for a disability in order to participate fully in this continuing education activity, please call (919) 962-2118 no later than March 5, 2010 or attach a note to your registration form.