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Registration: Pre Term Birth

Registration includes attendance at all lectures, syllabus, CME credits, continental breakfast, lunch and coffee breaks.

Cancellations: Refunds will not be issued for cancellations received after December 15, 2015. A processing fee of $40 will be retained on all cancellations.

Contact Information

Title

First Name

Last Name

Facility or Organization Name

Mailing Address

Unit, Suite, or Apartment

City

Province / State

Country

Postal / Zip Code

Business Phone

Fax

Your E-Mail Address

Please indicate your profession:

Profession Please select one

Obstetrician/Gynaecologist
Family Physician
Midwife
Nurse Practitioner
Nurse
Resident
Student
Other

Other profession Please specify

Payment Amount

Fee Group	Early Fees (on or before December 15, 2015)	Late Fees (after December 15, 2015)
Physician	$225	$250
Midwife, Nurse & Health Care Professionals	$175	$200
Resident/Students/Fellows	$100	$125

I will be submitting the following fee:

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