Application

To register: print this page (landscape), complete form, send via US mail along with check as below.

APPLICATION FORM
Diabetes Mellitus Seminar: From Theory To Practice
September 21-23, 2005

PLEASE PRINT CLEARLY

Name __________________________________________  Credentials _____________________________

Address ___________________________  Phone:day(____)_____________ night(____)_____________
        No PO Boxes please

City _________________________ State ___ Zip _________  Email ____________________________
                                                         Block letters please for course confirmation
Attending: Please check all days that apply:
Wednesday ___   Thursday ___   Friday ___ 

How did you hear about the course? _______________________________________________________


May we share your name with a potential roommate? Yes ___  No ___

____  Exam preparation?

____  Credential Maintenance?

Send check or money order made payable to:
Association for Medical Education
with this form to:
Ellen D. Mandel, PA-C, MPA, MS, RD, CDE
PO Box 56, Berkeley Heights, NJ 07922-0056

See Tuition Fees. Full fee must accompany application: checks and money order (sorry no credit cards)

# Days	________
TOTAL ENCLOSED	$________

___ I can not attend, please keep me on the mailing list
___ Remove me from the mailing list

No refunds will be mailed if notification is postmarked after September 7, 2005. Please email ellen@ameded.org for a personal confirmation. Email confirmations are sent one week prior to the course.