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 the other contact information you provide)

E-mail address: *   *   

Registrant Name:  *    *             
             
Professional Designation:  *   - please select from list -Family Physician Psychiatrist Other Physician (please specify below)PsychologistSocial WorkerNurseOther (please specify below)   *  
             If "Other", please specifiy:   
  
             
Address:   *     *      City:               
             
Province/State:            Country:  
             
Postal/Zip Code: 
             
Phone:  *    * 

Fax:             
             
How did you hear about the conference?:  *    * 
             
Accommodation required:  
 Yes
 No

     [If you require accommodation, please contact the Pillar and Post Inn
      directly [1-888-669-5566] to book a room. If you indicate you require
      accommodation, we will confirm you have been able to arrange
      accommodation prior to processing your registration.]

- - - - - - - - - - Conference Fee - - - - - - - - - - -

REGISTRATION FEE (7% GST tax included in fees listed below): 
   Paying in Canadian $ - Regular Registration: $444.05 Cdn Paying in Canadian $ - Resident/Spousal Registration: $315.65 Cdn Paying in USD - Regular: $425 USPaying in USD - Resident/Spousal: $300 USD

[please note, if registering under spousal registration, please complete separate
registration forms for primary registrant and spousal registrant]        
     

Please forward cheque for net amount,
payable to "Psychiatry Review Course", to:
Psychiatry Review Course
2 Jane Street, #204
Toronto, ON
Canada, M6S 4W3

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Please check to confirm you have read the "Terms and Conditions" for the September 2006 Psychiatry Review Course [click to go to link]:
Yes, I have read the Terms and Conditions for this conference * * (check box)

Other comments:

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

As per out Privacy Policy, Information submitted will be used for registration purposes and may also be used to keep you informed of future CME events. Information will not be shared with any third parties, unless that is required to facilitate registration or, when necessary, accommodation.

             

             
             
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]