Registration Page for March 12 - 19, 2005 International CME Conference

Once you submit your online registration information, you will be contacted for
completion of cabin bookings.  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:      
 Category 11, 184 sq ft, Standard inner stateroom
 Category 10, 214 sq ft, Deluxe inner stateroom
 Category 9, 214 sq ft, Oceanview stateroom
 Category 6, 268 sq ft, Verandah stateroom


Cabin preference - second choice:  
 Category 11, 184 sq ft, Standard inner stateroom
 Category 10, 214 sq ft, Deluxe inner stateroom
 Category 9, 214 sq ft, Oceanview stateroom
 Category 6, 268 sq ft, Verandah stateroom


Please indicate dinner seating preference:  
 Early seating
 Late seating


Please check to confirm you have read the "Terms and Conditions"
for the March 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 [until November 9, 2004]: $550
 Late Registration [After November 9, 2004]: $650

             
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 Carlson Wagonlit (in this case, "Carlson Wagonlit" will appear on credit card statement for registration fee payment)

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

             

             
             
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]