FPA Conference Registration Form - Fairview Physician Associates

Wednesday, Nov. 4

Full day conference with continuing education credits: only $45. Please enter the following information and register by Monday, Oct. 26.

Three ways to register:

1) Complete this form, print and FAX it to Fairview On Call with your credit card information. FAX to 612-672-6248.

2) Complete this form, print and sent by US MAIL with your credit card information OR check payable to "Fairview On Call" to:

Fairview On Call/FPA Conference

University of Minnesota Medical Center, Riverside Campus

2450 Riverside Ave.

Minneapolis, MN 55454

3) Phone Fairview On Call, 612-672-7272, and provide the information on the form, including your credit card information.

Name*

Organization affilation*

Home Phone*

Work Phone*

Credentials*

Area of practice or specialty*

Preferred Mailing Address*

Home Business

Address*

City*

State*

Zip*

E-mail Address*

Provide fax if no email

Credit Card Information:*

Visa MasterCard Discover

Credit Card Number

Expiration date

*= required fields. Please give us your daytime telephone number
even if you prefer another form of contact.