| COMPLETE
FORM ONSCREEN, THEN PRINT OUT.
MAIL OR FAX COMPLETED FORM AND PAYMENT
TO:
HELMS MEDICAL INSTITUTE
2520 Milvia St., Berkeley, CA 94704
Fax: 510-649-8692
For
additional information concerning this program call:
510 649-8488 or email: MAFP@HMIeducation.com
Enrollment
is limited - early application is recommended.
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Name:
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(First, Middle initial,
Last) |
Day
Phone: |
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Home:
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(Street Address Only, No P.O. Boxes) |
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City:
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Field of Practice: |
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State:
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Zip:
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Video
Course
Format: |
300-hr
220-hr
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Specialty
videos: |
Pain Management
Primary Care |
| SELECT
THE CLINICAL UNIT YOU WISH TO ATTEND: |
Fall
2008 venues: two 5-day clinicals
|
September 19-22, 2008
in Pittsburgh, Pennsylvania
December 9-14, 2008 in
Tempe, Arizona
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fee:
$2000 for
both 5-day units, (recommended)
or
$1500
for one 5-day unit.
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Check payable to: Helms Medical Insitute
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Charge (MasterCard, Visa, or Discover only)
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Card Number:
-
-
-
Expiration Date:
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| Authorizing
Signature: ____________________________
Date:__________________
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*
By Regental authority your Social Security# is required
in order to verify your identity for accurate recordkeeping.
Providing your birth date is voluntary. |
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SM
