Chicago Review Courses


Registrant: (individual to attend)
Name
Address
City
State		ZIP
Country
Home Phone
Fax
E-Mail Address
Medical School Attended
Year Graduated


I would prefer confirmation by: (check all that apply)
Phone	Fax	E-Mail
How did you hear about the course?
Mailer	Web	Banner Ad
Print Ad	Word of Mouth

Course Fee :
Please select a tuition category, and return your payment with this form to reserve your space.
$2125 Practicing Physicians

$1925 Residents*
$1025 Nurses
Early Bird Special (Before December 1, 2008)
$2000 Practicing Physicians
$1800 Residents*
*Residents must include a letter of verification from their Chief of Service Call (773) 296-6666 for more details.