"A QUESTION OF MERCY"
A Discussion of End-of-Life Issues
Monday Night, June 21, 1999
7:30 - 10:00, Lipsett Amphitheater		 nihslogo.gif (2913 bytes)

Workshop Online Advance Registration Form

To register by mail or fax, click here for a printed registration form. PDF format allows you to view your form electronically on most computers. The freely available Adobe Acrobat reader is required to view and print PDF files. Return the completed registration form to:

Capital Consulting Corporation
Attn: Traci Eng
11900 Parklawn Drive, Suite 350
Rockville, MD 20852
301-468-6004, x403
301-468-0338 (Fax)

Name:
First:
 MI:
Last:
Degree(s):
Position Title:
Affiliation:
If NIH:
Institute:

Lab/Office:
 If not NIH:
Affiliation:
Affiliation Address:
Building/Room Number:
Mail Stop Code:
Street Address:
City:
State/Province:

ZIP/Postal Code:
Telephone:
Fax:
E-Mail Address:
Are you a student?
Yes    No
If yes, please specify:
Level:

Major:
Why is this program of interest to you?:

Do you require any special accommodations (e.g. wheelchair access, signing, etc.)?
Yes    No
If yes, please specify:
  • You may experience a delay of 10 to 15 seconds while your online registration is being processed.
  • Once processed, you will be forwarded to a confirmation screen indicating that your online registration has been confirmed.
  • Please do not close your browser, use the "back" button, etc. until your registration is confirmed.
  • Thank you for your patience.