Full Name ____________________________       Institution ________________________________

Address (Same credit card billing address) ___________________________________________________

City ____________________ State ________  Zip (postal) Code __________ Country ____________

Daytime Phone _________________Fax #  __________________  E-mail _________________________

Payment (check appropriate checkboxes)                        Amount

▢ Registration Fees                                        ___________

▢  Workshop (IHC)                                                             $100

▢ Syllabus and DVD of 3rd annual course                        $150

▢ DVD of the 3rd annual course                                         $50

▢ Reception, Monday Evening                                            $40

     Total                                                                                $__________

  

Payment Method (One Option):

Check Enclosed (Payable to Pathology Learning Centers)

Credit Card: Charge to  (check one)             ▢  American Express        ▢ Visa        ▢ Master Card

Credit Card # _________________________         Security Code ______      Expiration Date ____________

Note: American Express security code is the four digits located on the front of the card.

          Visa and Master Card security code is the three digits located on the back of the card.

Signature _____________________________

Cancellation Policy: Requests for cancellation received in writing up to 3 months prior to the start of the course will be refunded the full amount minus a $75 processing fee. Requests received between 3 months and 1 month prior will be refunded 50% of the registration fee. Requests received within 30 days of the course will be refunded 20% of the registration fee.