Registration Form

 

Name

First MI Last Degree(s)

SSN __ __ __ - __ __ - __ __ __ __ Business Phone

Street Address

City/State ZIP

E-mail Address

Specialty

 

Tuition: Early Bird (Before April 14, 2000 based on postmark): $595.00

Standard: $645.00

A limited number of discounted positions are available for residents. Call 216-844-5050 for information.

Parking: $30.00

Total enclosed: $_________

 

____ Enclosed is my check payable to: University Hospitals of Cleveland

 

Charge my: ____VISA ____MasterCard ____AmEx ____Discover

Card #:_______________________________________________________

Expiration Date:_______________________________________________

Signature:_____________________________________________________