Application for Continuing Medical Education Program

Name_______________________________________________

Address_____________________________________________

City________  State_____  Country _______  Zip Code______

Phone Number_______________    Cell___________________

Email_______________________________________________

The required fee for each 1.5 day program is $1200.00

(non-refundable) and must accompany the application.

Please make checks payable to:

International Research Foundation for RSD/CRPS

1910 E. Busch Boulevard

Tampa, FL  33612

Phone: 813 907-2312

I wish to attend the following Program(s):

Please check the box or boxes below:

      Dr. Timothy Lubenow  --  Academic

                                              Chicago, IL

       Dr. Fernando Cantu – Coma Study

                                              Monterrey, Mexico

     Dr. Anthony Kirkpatrick – Private

                                              Tampa, FL

Signature_________________________________    Date _______________