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DERMATOLOGY UPDATE REGISTRATION FORM
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REGISTRATION INFORMATION
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___ Mr. ___ Ms. ___ Dr.___ Title _________________________________
Name _____________________________________________________________
  (As you would like it to appear on your badge.
  Note: maximum 19 characters. Please print.)
Affiliation ______________________________________________________
Address __________________________________________________________
City ___________________________ Prov/State ______________________
Country ______________________________ Code ______________________
Telephone (_______) _________________________
Fax       (_______) _________________________

FEES (see Registration Fees)
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Symposium Registration..............................$_____________
_____ # Guest Tickets to Friday night reception.....$_____________
Social Program (Residents only).....................$_____________
Friday Breakfast Session............................$_____________
  What the Internet Means to the Practicing Dermatologist
Saturday Breakfast Session..........................$_____________
  Professional Liability of Dermatologists in Canada
Workshops (Note concurrent sessions)
__ Typical Leg Ulcers (Thurs, 7:00 - 9:00 p.m.)......Complimentary
__ BOTOX (Sun, 9:00 a.m. - 11:00 a.m.)..............$_____________
__ Venous Leg Ulcers (Sun, 9:00 a.m. - 12:00 p.m.)...Complimentary
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Sub Total...........................................$_____________
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7% GST for CDN residents/3% for non-residents.......$_____________
  GST Reg. #R127493351
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TOTAL ENCLOSED......................................$_____________
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METHOD OF PAYMENT
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___ Cheque enclosed (Payable to Dermatology International.)
___ VISA ___ MasterCard
Card Number ______________________________________________________
Expiry Date ________ Name of Cardholder __________________________
  (Note: All funds processed on credit cards will be in the
  Canadian rates quoted.)

CANCELLATION POLICY
-------------------
Refunds (less a $25 administration fee) will be given for 
cancellations received in writing postmarked no later than 
September 20, 1996. Refunds will not be available after this 
date. I have read, understand, and agree to the general conditions
and cancellation policies.

Signature ___________________________________ Date _______________

Please keep a copy of this form for your records. Registration
will be acknowledged with a confirmation letter.

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Dermatology Update.

Internet Version: 25Sep96