Registration Page for November 6-13, 2005, International Conference

Once you submit your online registration information, you will be contacted for
completion of cabin bookings. Alternatively, if you wish to contact Thomas Cook yourself you can via phone at (416) 622-8161 [please call collect for long distance]; fax at (416) 622-1782; or e-mail at dweir@thomascook.ca (Debbie) or lwilkinson@thomascook.ca (Lois).

Your registration will be processed once you are
able to obtain the accommodation you need.

Fields marked with * must be filled before online form can be submitted

Please enter a valid e-mail address where you can be contacted (if you do not have
e-mail, you may still use this form by entering "register@psychiatryreviewcourse.com"
in the field below - we will then contact you with other contact information you provide)

E-mail address: *    

Registrant Name (as it appears in passport): *               
             
Professional Designation: *   
 Family Physician
 Psychiatrist
 Other Medical Specialist
 Other Professional
             
             If "Other", please specifiy:   
   (Please note, this is solely for the purposes of identifying the demographics
   of conference attendees.  You may indicate at time of booking whether you
   wish travel documents to bear the designation of "Dr.", "Ms.", "Mr.", "Mrs.", etc.)
             
Address:  *                 City:                    
             
Province/State:            Country:  
             
Postal/Zip Code: 
             
Phone: *  

Fax:             
             
How did you hear about the conference?: *  
             
Name of travelling companions (as they appear in passports; list ages for children):

    1.           2.           3. 
   [if additional companions, please write in the "comments" field below]

Cabin preference - first choice:      
 Inner stateroom
 Oceanview stateroom
 Balcony stateroom


Cabin preference - second choice:  
 Inner stateroom
 Oceanview stateroom
 Balcony stateroom


Please indicate dinner seating preference:  
 Traditional Early seating
 Traditional Late seating
 "Anytime" dining 


Medical and/or Travel Insurance (recommended):  
 Accepted
 Declined


Flights required:  
 Yes
 No


Transfers to/from port required:  
 Yes
 No


Please check to confirm you have read the "Terms and Conditions"
for the November 2005 Psychiatry Review Course [click to go to link]:

          Yes, I have read the Terms and Conditions for this conference *    (check box)
             
Registration Fee (in Canadian dollars; no GST): *  
 Regular Registration: $550 Cdn
 Resident/Spousal Registration: $335 Cdn

     [registrations by May 28, 2005, eligible for "Attend for free" draw]
        
Check box if eligible for "Introduce a Colleague" $75 deduction:              
             
             Name of colleague (if eligible for above deduction): 
             
Other comments:      
             

Cheque should be made payable to "Psychiatry Review Course" and mailed to:
Psychiatry Review Course
2 Jane Street, #204
Toronto, ON
Canada, M6S 4W3

- or -

Registration may be paid by credit card at time of cabin booking with Thomas Cook travel (in this case, "Thomas Cook" will appear on credit card statement for registration fee payment)

Please note, space cannot be held until registration is complete and payment received.

Information submitted will be shared with Thomas Cook to facilitate bookings, and may also be used to keep you informed of future CME events.

             

             
             
Once you click above to submit your information, a page thanking you for submitting the form
should appear if the information was successfully submitted.  You may then use the "BACK"
button on your browser to return to this page.

Thank you for your interest in the course.  You will be contacted via e-mail shortly.

[click here to return to the Psychiatry Review Course homepage]