REGISTRATION FORM (Please Print or Type)
Name (First, MI, Last) Degree 
Address
City State Zip Code Country
Telephone (including area code) Fax (including area code)
Email address
Registration
Physician
Nurses (License Number)
Allied Health Professionals
Industry Personnel (Company)
Governmental Employee
Accompanying Person(s) Names 12 & Older
Name(s)
TOTAL AMOUNT ENCLOSED $
Payment Method (specify)
Check in US funds made payable to MADRI is enclosed
Please charge my          Visa MasterCard Discover Card
Credit Card Number
Expiration Date (Month/Year)
Name as it appears on card (Please Print)
Signature
Return completed registration form and payment (check or credit card information) to: MADRI, PO Box 865, Bastrop, TX 78602-0865. Alternatively, registrations paid by credit card can be faxed to 512 985 5073.
For more information contact Donna Jones at djones1pmr@aol.com or 832 326 9613.

Registration Information

Registration Includes: Educational Accreditation, Syllabus, Breaks, Lunch, Continental Breakfasts, and Dinner
  By May 2, 2011 After May 2, 2011
Physicians $ 350.00 $ 400.00
Nurses/Allied Health Professionals $ 300.00 $ 350.00
Residents/Fellows in Training $ 250.00 $ 300.00
Industry Personnel $ 400.00 $ 400.00
Governmental Employees Contact Donna Jones (djones1pmr@aol.com)