subject_line
CME & CULTURAL TOUR OF JAPAN
MAY 2024
(Specific dates to be finalized shortly)
PRE - REGISTRATION FORM
GROUP MEDICAL DIRECTOR:
DR. STEVE SZARKA, HAMILTON, ON.
NO DEPOSIT REQUIRED !
Registrant Information
Title
*
First Name
*
Surname
*
Number of registrants in your party:
*
1
2
3
4+
Number of rooms required: *
1
2
Single room
1
2
Double room
1
2
Triple room
Contact Information
Street Address
*
Address Line 2
City
*
Province/State/Region
*
Zip/Postal Code
*
Country
*
Phone No. (home/cell)
*
Phone No. (business)
Fax No.
Email Address
*
CME Program Newsletter updates - please send me future notifications by e-mail
Yes
No
How did you hear about Doctors-on-Tour?
Advertisement (Medical Post)
Advertisement (Doctors Review)
Existing client of Doctors-on-Tour
Group Medical Director
Fax Marketing
CME conference listing
Google search
Other