2001 Physician Seminars REGISTRATION FORM

2001 Physician Seminars REGISTRATION FORM
To register, call Mikich Inc. at 800.733.6808, or Print this form and complete the requested information (neatly, please), and FAX to Mikich, Inc. at 919-933-3771, with Visa or MasterCard credit card information. We do not accept American Express. Or mail with credit card information or check to: Mikich Company, Inc. PO Box 701, Carrboro, NC 27253.

PLEASE REGISTER ME FOR:
___	2001 Medical Witness Summit ($995)	October 13-14, 2001
___	Medical Malpractice: Advanced Survival Training For Physicians ($995)	October 11-12, 2001
___	Medical Fiction Writing For Physicians ($995)	October 26-28, 2001

Enclosed please find tuition of ___________

	Check Enclosed (made out to Mikich Company, Inc.)
	Credit Card Billing	Type of card: ___Visa ___MC
Card No.		Exp. Date:
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