Registration Fees (Due at the Time of Registration)

Interdisciplinary Oncology Symposium March 4, 2016

Registration Fees (due at the time of registration): Standard On-site ends March 1 3/2/16 through 3/4/16 Physician $175 $200 Beaumont / OUWB Non-Physician $100 $125 Faculty & Resident/Fellow Fee Waived $50 Staff 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 [email protected] 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 [email protected] 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 Degree Affiliation Specialty Beaumont ID Physical, Dietary, (if applicable) other needs

Address 1 Address 2 City State Zip

Phone Email*

Payment by Credit Card: VISA MASTERCARD DISCOVER AM/EX

First Name Last Name

Billing Address City ST Zip

Credit Card # Exp (MMYY) CCV Return completed form to: [email protected] or 248-551-0908

Total Paid: $