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contact us: mafp@HMIeducation.com
2520 Milvia St., Berkeley, CA 94704

 tel: (510) 649-8488
fax: (510) 649-8692

APPLICATION FORM
FALL 2008 / SPRING 2009 Course


Co-Sponsored by Helms Medical Institute and the Office of Continuing Medical Education,
David Geffen School Of Medicine at UCLA 
Introductory Unit: 4-7 December 2008, Tempe, Arizona

COMPLETE ONSCREEN, THEN PRINT OUT AND SEND IN.
Enrollment is limited - early application is recommended.
This application cannot be processed without:

Application for Enrollment Form Resume
Photocopy of Current Medical License Statement of Plans
300-Hour Tuition: $6,600 ($6,750 after 31 October)
     $5,300 Discounted Tuition: ($5,450 after 31 October): full-time residents and fellows only
220-Hour Tuition: $6,300 ($6,450 after 31 October)
     $5,000 Discounted Tuition: ($5,150 after 31 October): full-time residents and fellows only
optional Clinical Intensive on Monday December 8: $600 ($700 after 3 March) 
Exposure Program (Residents/Fellows only) $1,600 ($1,750 after 31 October)
optional additional pathway study with Spring 2009 clinical units (100 extra CME credits) $2000
Name:


(First, Middle initial, Last)  
Soc.Sec. number last 4 digits: 
xxxx- xx-
Birth Date: 
/ /
Address:

(Street Address Only, No P.O. Boxes)
Day Phone: 
Home: 

Fax:

City: 

Professional Degree & Field of Practice: 

State:

     Zip:

Email: 
Course 
Format: 
300-hour        220 Hour       Exposure Program    
Unit III 
Pathway: 
Pain Management       Primary Care   

Unit III locations: 

There are two required 5-day clinical units included with the 300-hour or 220-hour course:
20-24 March 2009 in Pittsburgh, Pennsylvania
and
20-24 May 2009 in Tempe, Arizona
PARTICIPANTS MUST COMMIT TO ATTEND BOTH CLINICAL UNITS.

Check payable to: Regents of the University of California
Charge  (MasterCard, Visa, or Discover only)

                           
Card Number:        - - -     Expiration Date:

Authorizing Signature: ____________________________ Date:__________________
* By Regental authority your Social Security# is required in order to verify your identity for accurate recordkeeping. 
  Providing your birth date is voluntary.

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
This program is limited to 160 participants. Please apply early.
The Introductory Weekend course is held at the Tempe Mission Palms Hotel.
A group rate of $152/night plus tax has been arranged for you:
Tempe Mission Palms Hotel
60 East Fifth Street
Tempe, Arizona 85281
(480) 894-1400
The hotel is a 15-minute taxi or shuttle ride from Phoenix Airport.

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