Use this form to enroll in this program. Please fill out completely and mail to:
Arnold & Marie Schwartz College of Pharmacy and Health Sciences; 75 DeKalb
Avenue, Room 207, Brooklyn, NY 11201-5497 or fax to 718-780-4055.
Name _________________________________S.S.#__________________________
Address ______________________________________________________________
Phone (______)________________ Email Address ____________________________
( )Enclosed is my check for $100.00 - the November 15, 2009 CE program (checks
payable to AMS Pharmacy CE)
or
( )
Charge my credit Card for the November 15, 2009 program:
( ) MASTER CARD
( ) VISA
( ) AMEX
( ) DISCOVER
Card Number _______________________________________
Exp Date _______________
Cardholder Signature ______________________________________________
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