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To contact us:
Broda O. Barnes, M.D.
Research Foundation, Inc.
P.O. Box
110098
Trumbull, CT 06611
Phone: 203-261-2101
Fax: 203-261-3017
Email:
info@BrodaBarnes.org
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Conference Registration
Annual Fall Endocrinology Conference
October 15 -17, 2004
To register for this conference, please print the
following form, complete and return it to:
Barnes Foundation
P.O. Box 110098
Trumbull, CT 06611
Credit card payments may be faxed 24 hours a day
to: 203-261-3017
Registration Information:
Physicians/Medical Practitioners
- $575.00 per person
Participating Spouse/Student and
Non-Physician Staff Member: $450.00 per person
Barnes Membership Society
Members $495.00 per
person.
Conference fee includes
continental breakfast, lunch and refreshment breaks.
Final Registration Deadline:
September 15, 2004. No refunds will be given after that date. There is a
$50.00 cancellation fee for all registrations.
Please use photocopies of this form
for multiple registrations.
please print clearly
First Name: ________________________
Middle Initial: __________
Last Name: _________________________
Degree: ___________
Affiliation:_________________________________________
Address:_________________________________________
City: __________________ State: _______
Zip Code: ______________
Home Phone: ____________________
Work Phone: _________________
Fax Phone: _____________________
e-mail address: ________________
Name of Additional Attendee(s):__________________________
Member of the Barnes Membership Society
________Yes
________No
Please indicate Total Amount: $
Check or Money Order Enclosed
(payable to Barnes Foundation) _________
Credit Card (please circle one) Master Card Visa Amex
Diners JCB Discover
Account #________________________________________
Expiration Date _________
Signature
________________________
Registration deadline is September 15, 2004. No
refunds will be given after that date. There is a $50.00 cancellation fee
for all registrations.
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