2011 Registration form3rd Annual PBRN Convocation

October 22, 2011PlEASE PRINT

Name:______________________________________________________________________________________________

Credentials: MD DDS DO RN PA PhD PHarmD Other

Affiliation: Network Member Faculty Clinician Student Resident TAB Member

Network Affiliation: STARNet RRNet South Texas Psychiatry VA Mental Health PRENSA

STOHN Other:___________________________________________________________

Specialty:___________________________________________________________________________________________

* Practice Site: Private Practice FqHC HPSA RHC MUA NHSC Hospital Based

Organization/Practice

Name: ______________________________________________________________________________

Address: ______________________________________________________________________________

City____________________________ State _______ Zip_______ County________________

E-Mail: ______________________________________________________________________________

Telephone: _______________________________ FAX __________________________________________

* Age: under 20 20-29 30-39 40-49 50-59 60 & over * Gender: M F

* Ethnicity: Caucasian African American Hispanic Asian Other _____________________

*Required for grant #D54HP16444

Registration Fee: $50.00 Payment method: Check Credit Card Bill Me

Registration Methods

Email: moris@uthscsa.edu (scan and email or fill out electronically and click the submit button)

By mail (include registration form with your check or credit card information)

UT Health Science Center SA PBRN Resource Center 7703 Floyd Curl Drive, MC 7728 San Antonio, TX 78220-3900

By fax: 210-567-7868 (include registration form with credit card information)

Credit Card Please charge $______________________ to:

VISA Mastercard Discover American Express

Card Number: ____________________________________________CSC ___________Exp. Date: ____________________

Cardholder Name:________________________________ Signature ____________________________________________

(choose all that apply)

(Make Checks payable to: South Central AHEC)

(Visa & MC last 3 numbers on the back)

“DISCOVeRINg The POweR & POTeNTIAL Of TRANSLATIONAL ReSeARCh”