NECF 1st Annual Conference –
Meeting the Need: Policy and Practice

New England Clinicians Forum presents
A conference dedicated to the healthcare needs of the underserved.

November 7, 2003 – The Providence Mariott
Please fill out the form below and then hit SUBMIT to register online. Please note that registrations WILL NOT be processed without payment.

Registration Fee $65
Registration Deadline: October 23, 2003

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First Name:
Last Name:
Title:
Organization:
Address:
City:
State:
ZIP:
Email:
Phone:
Fax:
I will be attending:	Conference ($65)
	Special Breakout Session: Research

I will be using my Credit Card:	MasterCard	VISA
	Account #:
	Exp. Date (mm/dd/yyyy):
Name as it appears on credit card:
ZIP Code of billing address:

I will be printing this form and mailing it to:
CPCA, 90 Brainard Road, Suite 101, Hartford, CT  06114  Attn: Amelia Hoeger
I will be faxing this form with the credit card information to:
CPCA 860-727-8550