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Please print form and mail or fax to WSP.
(See mailing address below; fax 202-237-2730)
Name
_____________________________________________ Degree
_____________
Name for name tag
________________________________________________________
Major Profession
__________________________________________________________
Mailing Address
___________________________________________________________
City __________________ State __________ Zip Code
__________________
Work phone (_____)_________________ Home
Phone (_____)____________________
Other phone (_______________)
____________________________________________
Fax (___)________________________ Email Address
__________________________
Short course, seminar, conference or other event(s) for which you are applying:
Title(s) Date(s)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
_________ Total registration fee(s)
enclosed
*Make checks payable to Washington
School of Psychiatry. All cancellations are subject to a a
non-refundable administrative fee of $50.
O Please bill my credit card for the
total amount indicated above.
O Master Card O VISA
Account Number
_____________________________________ Expir. Date ____________
Signature ________________________________________
(must be provided to charge)
Send or fax this completed form and fee to:
Registrar
Washington School of Psychiatry
5028 Wisconsin Ave., NW, Suite 400
Washington, DC 20016
Tel: 202-237-2700
Fax: 202-237-2730 |
