Fall 2007 Pharmacology Registration - (please print, complete and submit))

 
Name  
Address  
City, State, Zip  
Home Phone  
Employer  
Title  
Work Phone  
E-Mail  

 
Pharmacology:           Full course ______
Individual Days Only - (Please indicate) Fri. _____  Sat. _____    Fri.  _____     Sat. _____     Fri.  _____     Sat. _____

Single day

     @ $ 219.00 $                                          

Two or more Days

  # Days____ (Each)       @ $ 199.00 $                                          

Entire Pharmacology Course

   @ $ 999.00 $                                          

Sub-Total

 $                                          
Only one discount allowed:

Identify Discount Status: University of Pennsylvania: 
Faculty      Alumni      Full time Students    
  
UPHS, CHOP & Philadelphia VA  Nursing Staff                                 Minus 15 %
Please circle affiliation

 $                                          


TOTAL 

$                                          
Credit Card Payment:

Visa # or MC (only) #                 /                 /                 /                           

Expiration Date:                /                Amount $                                

Check Payment
CHECKS PAYABLE to 
 Trustees of the University of Pennsylvania:
Check # __________
Amount $_________

Fax: Registration To 215-573-9103   
Mail: Registration and Payment to:   Janet Tomcavage
                                                        University of Pennsylvania School of Nursing
                                                        420 Guardian Drive
                                                        Philadelphia, PA 19104-6096