Pre- Registration Form

First Name
Family Name/Other Name
Qualification
Sex	Male Female
Address
City	Zip:
State
Country
Phone
Fax
Email
Name of the Event you are Registering
Indicate the venue where you will attend the event.(please name the venue from the one's where the event will take place)


I want the UAB certificate (Please note that the foundation will facilitate UAB CME Certificate only in venues where UAB faculty is part of the workshop/course faculty)	Yes No The University of Alabama at Birmingham, USA (UAB) Continuing Medical Education (CME) certificate for Credit Hours will come pre-printed based on the information you have given above. This special certificate will be available to the participants at a nominal fee of USD$10 (Equivalent local currency) which will be collected at the time of the event. This is a standard fee that is payable to UAB CME department who will issue the certificate. You can write to us if you need some more information on the same. This amount will be over and above any Registration fee that may be charged.
Any additional information you want to give