<% if (request.ServerVariables("SERVER_PORT_SECURE") <> "1" or request.ServerVariables("HTTPS") <> "on") then Response.Redirect("https://www.barry.edu/podiatry/cme/SeminarForm.asp") end if %> School of Podiatric Medicine, School of Podiatric Medicine, Barry University
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2010 Comprehensive Board Review Registration Form

December 26-30, 2010

This is a secure site and your information is protected.

Name:
Office Address:
City:
State:
zip:
Office Phone:
Fax:
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LICENSE INFORMATION:

State      License #

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State      License #

State      License #

Mock Oral Interview Selection:

Forefoot
Rearfoot / Ankle
Both
Orthopedic and Primary Podiatric Medicine
Option 1: Lecture only = $650.00 (by April 20, 2009, postmarked after this date $750.00)
Option 2: Lecture + mock oral interview = $650.00 (by April 20, 2009, postmarked after this date $750.00)
Option 3: Lecture + extra oral interview = $730.00 (by April 20, 2009, postmarked after this date $830.00)
Please charge $ to my credit card
Charge my:
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Card No.:
Exp. Date:(MM/YYYY)
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Name/address/zip-of card:

Please contact Urmala Roopnarinesingh at 305-899-3255 or Solange Brinson 305-899-3255 if you have any special needs.