Check one:
Check/money order payable to
Hospital Education in the amount of .......... $ __________
MasterCard or VISA
in the amount of ............................................. $ __________
Account Number _____________________________________________
Expiration Date ______________________________________________
Name of Card _______________________________________________
Signature as it Appears on Card _________________________________
Check or money order should be made payable to Hospital Education. Mail or fax (credit card only) entire registration form to:
Registration
Box 3883
Duke University Medical Center
Durham, NC 27710
Fax: (919)-681-6251 |