__________________________________________________________________
Position
__________________________________________________________________
Name of Medium
__________________________________________________________________
Address
__________________________________________________________________
City
__________________________________________________________________
State
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Zip
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Phone (Office)
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Fax
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Phone (Home)
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Phone (Cell)
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Pager
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Email
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Kind of news you cover
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Dietary restrictions,
if any
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Conference Fee $95.00.
___ Payment by check or money order is included.
(Make check payable to Wake Forest University School of Medicine.)
___ Please charge my credit card for total
due.
Credit card type: ___ VISA ___ MasterCard
Credit card number
__________________________________________________________________
Name as it appears on card
__________________________________________________________________
Signature
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Please mail with payment to:
Addiction Studies Program for Journalists
Wake Forest University School of Medicine
Winston-Salem,
North Carolina 27157-1083
Or
fax (credit card only) to 336-713-7168.
Confirmation of registration and/or scholarship
will be received within 1 week after registration deadline.
No conference fees can be refunded due to cancellation after
confirmation is received. Journalists who receive scholarships
and later cancel will be billed for the cost of holding their
room and their airline ticket.
For
more information call 336-713-7161.
