Download the 5th annual international dermatology exchange program

REGISTRATION FORM
14TH ANNUAL INTERNATIONAL DERMATOLOGY EXCHANGE PROGRAM
of THE SKIN CANCER FOUNDATION
April 5 –7, 2013 San Juan, Puerto Rico
Co-Directors:
Perry Robins, MD
Deborah Sarnoff, MD
 Enclosed is a check (or credit charge) payable to The Skin Cancer Foundation in the amount of $500. I
plan to attend the conference in Puerto Rico, and understand that this registration fee serves as my annual
membership fee to The Skin Cancer Foundation, which is tax deductible.
 Credit card:  VISA  MasterCard  AmEx
Account No._______________________________
Expiration Date____________________
Name on card______________________________
Signature_________________________
Credit Card Billing Address:__________________________________________________________________
________________________________________________________________________________________
NAME:
________________________________________________________________________________
ADDRESS: _______________________________________________________________________________
________________________________________________________________________________
PHONE:
________________________ FAX:_____________________ E-MAIL:____________________
Name(s) of accompanying person(s):____________________________________________________________
Upon receipt of your Registration, you will be given hotel registration instructions.
Please complete and return this form with your tax-deductible registration/contribution to:
The Skin Cancer Foundation
149 Madison Ave., 9th floor
New York, NY 10016
Phone: (212) 725-5176  Fax: (212) 725-5751
e-mail: [email protected]  www.skincancer.org