Registration Form Providence-Providence Park Hospital, Southfield Michigan
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- Bu səhifədəki naviqasiya:
- First Name: _________________________ Last Name: ______________________Middle Initial: __________
First Name: _________________________ Last Name: ______________________Middle Initial: __________Degree: D.O. /M.D. Res. / Fellow/ StaffHome Address: ___________________________________________________________________________ Street City State Zip Code Cell Phone# _______________________________ E-Mail__________________________________________________________________________ ATLS Course Date: Sep 22 & 23, 2016 Please complete the section which applies to you: Fee schedule for St. John Providence Hospitals ------_$800 Hospital Name:________________________________________________________________________________________ Business Unit #: _________________________ Department Name: ___________________________ Dept #: ______________________ Approved by (print Name): ___________________________________________ Signature: _________________________________ Fee schedule for other Hospitals --------- $800 Hospital Name: ___________________________________________________________________________________________________________ Address: __________________________________________________________________________________________________________________ Department: _____________________________________________________________ Approved by (print Name): _________________________________________________Signature:_________________________________ Please make your check or money order out to Providence Hospital ATLS Course. Return the form by mail, fax, or email. Please fill out the form completely. Attention: Hillary Stone, Department of Medical Education 16001 W 9 Mile Road Southfield, MI 48075 Email: Hillary.vandusen@stjohn.org Phone: 248-849-5481 Fax: 248-849-5366 You will receive confirmation, directions and study material upon receipt of form by mail, if you do not hear back please contact Hillary Stone or Joann Burrington at 248-849-2729, email: Joann.Burrington@stjohn.org Yüklə 20,84 Kb. Dostları ilə paylaş:
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