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CME & CULTURAL TOUR OF SRI LANKA
OCTOBER 26 - NOVEMBER 12, 2023
PRE - REGISTRATION FORM
GROUP MEDICAL DIRECTOR:
DR. MEL BORINS, TORONTO, 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
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Group Medical Director
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