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Please note: registration deadline - September 10, 2005
ASSOCIATION OF CHAIRS OF DEPARTMENTS OF PHYSIOLOGY (ACDP)
2005 ANNUAL MEETING – Salt Lake City, UT
(in conjunction with the AAMC Basic Science Chairs Meeting)
OCTOBER 5-6, 2005
Name as you wish it to appear on your name tag:
Your Last Name
First
M.
Guest's name as you wish it to appear on name tag:
Guest's Last Name
First
M.
Mailing Address: _____ Home _____ Institution
Institution (if applicable)
Department (if applicable)
Street Address
City
State
Zip Code
Day Phone
Fax
Email
I (and/or my guest) have a disability that requires special arrangements (please
specify)
I (and/or my guest) have food preferences (i.e., vegetarian, restricted diet)
(please specify)
Registration Fees
ACDP Member
$100
Non-member
$125
Guest
$ 50
Total Registration Fees Enclosed: ______
Method of Payment:
______ Check (Payable to ACDP)
______ MC/VISA/Am. Express (Circle One)
Card Number:____________________________________Exp. Date:_________
Please forward this form by Sept. 10 and your registration fee to:
Melinda Lowy, Executive Assistant
ACDP
9650 Rockville Pike, Suite 314
Bethesda, MD 20814-3991
email: mlowy@the-aps.org
fax: 301-634-7098
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