Registration fee for Vanderbilt University School of Medicine/Corporate Health Services
"Medical Management of the Injured Worker XI" conference on March 30, 2012
is $200.00 for physicians (this includes CME fees) and $100.00 for all others.
This fee includes breakfast, lunch, breaks and conference materials.

PRE-REGISTRATION WILL END ON March 16, 2012.
Walk in registration will be available on the day of the conference for an additional $25.00.
NOTE: Availability of conference materials and food cannot be guaranteed
for those who register on the day of the conference.

No registration fees will be refunded after March 23, 2012.

Discounts are available for multiple attendees from a single company.
Call Tammie Mathis at 615-936-2098 for more information on discounts.

NAME

COMPANY

STREET ADDRESS

CITY/STATE/ZIP CODE

PHONE/FAX NUMBER

E-MAIL ADDRESS

DESIGNATION:

Physician	Case Manager	Adjuster	Employer
Nurse	PT/OT	Attorney	Other

STAYING AT MARRIOTT COOL SPRINGS OR OTHER HOTEL?

YesNo

WHAT TYPE OF CEU'S DO YOU REQUEST?

CCMC (for case managers)

CME (for physicians)

for PT's

None

REGISTRATION FEES:

$100.00 for non-MD's

$200.00 for MD's (this includes the cost of CME's)

Other Amount

Check (Make payable to Vanderbilt Corporate Health Services

YesNo

Mail to: Vanderbilt Corporate Health Services, Attn. Tammie Mathis
3319 West End Avenue, Suite 950, Nashville, TN 37203

OR BILL MY:

VisaMastercardAMEX

Cardholder Name

Card Number

Expiration Date

Security Code (3-digit code on back of card)

REGISTRATION FOR 2012 CONFERENCE

DEMOGRAPHIC INFORMATION

FEES AND BILLING