2015 Madison Clinical Conference The Pharmacists Role in Management of the Patient with Diabetes March 24-25, 2015 Three ways to register: 1. Online at http://ce.pharmacy.wisc.edu/2015MadisonClinicalConferenceInfo 2. By phone at 608-262-3132, toll-free at 877-947-4255 or fax at 608-262-2431 3. Mail this completed form with check payable to University of Wisconsin. Mail to: UW-Madison School of Pharmacy, 2015 Madison Clinical Conference, Division of Pharmacy Professional Development, 777 Highland Ave, Madison, WI 53705-2222 REGISTRATION RATES o o o o $265 Pharmacist Registration $350 Pharmacist Registration after March 2 $165 Pharmacist Registration-Single Day $190 Retired Pharmacists/Clinical Instructors (must be received by March 2 to qualify) Name _________________________________________________________________ Last First Middle I. Address _______________________________________________________________ City __________________________________ State _______ Zip _________________ Telephone (______) ________________ Fax: (______) ____________ Email Address* __________________________________________________________ *An email address is required to receive confirmation of your registration. You will receive emails from [email protected] Indicate Workshop choices/preferences: First________; Second________; Third________; Fourth________; Fifth________ (Please use the letter-e.g., A,B,C,etc.-corresponding to the “Session” title as indicated in the brochure to identify your choices. Session assignments will be made in order of receipt of registrations. Please list five choices; while every attempt will be made to provide you with your top three choices, no guarantees can be made.) Make checks payable to the University of Wisconsin We accept: MasterCard, Visa, Amer Express, Discover Card Number _____________________________________________Expiration Date ____________________ Cardholder’s name __________________________________________________________________________ Mail or fax to: UW-Madison School of Pharmacy 2015 Madison Clinical Conference Division of Pharmacy Professional Development 777 Highland Avenue Madison, WI 53705-2222 fax: 608.262.2431 Questions: Contact: Dr. Al Hanson Conference Coordinator PHONE: 608.262.3132 email: ce.pharmacy.wisc.edu Refund Policy: If it is necessary to cancel a registration, a refund, less an administrative fee of $50, will be provided if notification is received prior to March 2. No refunds will be issued after that date.
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