|
|
|
REGISTRATION
FORM 43RD Annual Seminar for GI
Nurses & Associates Seminar Saturday, September 21st,
2018 Hilton Los
Angeles/Universal City 555 Universal
Hollywood Drive Los Angeles, California |
PLEASE PRINT CLEARLY
____________________________ ___________________________
Last
Name: First Name:
Credential:
q RN q LVN q NP q CNA q MD q Other____
________________________________________________________
Address Unit/Apt
#
___________________________________________________-____
City State Zip Code
(___)___________ (___)____________ ______________________
Contact
Phone Work Phone Email Address
Required for registration
confirmation
___________________________________________________________________
Work Facility
License Information
____________________________ _______________________
License
Number: State
Mandatory for Nurses, as required by Nursing State Boards
_________________ ____________________ _________________________
Amount
Enclosed: Check Number: Cedars-Sinai/UCLA Emp ID#:
q Vegetarian Meal
|
MAKE
CHECKS PAYABLE TO: C.U.R.E.
Foundation Return This
Form To: Loretta So, RN GI Nurses
Seminar 9854 National
Blvd #266 Los Angeles,
CA 90034 |