Interdisciplinary Oncology Symposium
March 4, 2016
Beaumont /
OUWB
Faculty &
Staff
Registration Fees (due at the time of registration):
Standard
ends March 1
On-site
3/2/16 through 3/4/16
Physician
$175
$200
Non-Physician
$100
$125
Resident/Fellow
Fee Waived
$50
OUWB Medical Student
Fee Waived
$50
Physician
$225
$250
Non-physician
$125
$150
Resident/Fellow
$75
$100
Medical Student
$75
$100
Cancellation policy: Cancellations or refund requests must be received by March 1, 2016. A processing
fee of $25 will be assessed to all cancelled registrations. Cancellation or refund requests after March 1 will
not be honored. To cancel a registration, please send an email to cme@beaumont.edu with
“Interdisciplinary Oncology Registration Cancellation” in the subject line.
Directions: Complete the form with all required information. Return completed form with
credit card payment information to cme@beaumont.edu or fax to 248-551-0908 – or – mail
completed form with check payment to: 3601 W 13 Mile Road, ABW-112, Attn: Brooke
Taylor, Royal Oak, MI 48073.
A confirmation and payment receipt will be sent via email upon registration.
First Name
Last Name
Affiliation
Specialty
Physical, Dietary,
other needs
Beaumont ID
(if applicable)
Address 1
Address 2
City
State
Phone
Payment by Credit Card:
Degree
Email*
VISA
MASTERCARD
First Name
Billing Address
Credit Card #
Zip
DISCOVER
AM/EX
Last Name
City
ST
Exp (MMYY)
Zip
CCV
Return completed form to: cme@beaumont.edu or 248-551-0908
Total Paid: $