Registration Form CARDIOLOGY: New Perspectives & Clinical Challenges Please Print Name: ________________________________________________________ Mailing Address: ______________________________________________________ ________________________________________________________ City: ___________________________ State: ______ Zip: ________ Telephone: _____________________________ Fax: ____________________________ Email Address: ___________________________________ Registration Fee: $110 standard fee Early Registration Discount (before 4/9/04): $99 DC Academy Members: $65 Pennsylvania Veterinary Medical Association Members: $90 Payable by check, VISA or MasterCard (circle one) Credit Card Number: _______________________________________ Exp Date: _______________ Print Name on Credit Card: _________________________________________________ Signature: ________________________________________________ Fax form to: 703-742-8745, or mail to: DC Academy of Veterinary Medicine, P.O. Box 710477, Herndon VA 20171 For more information, or to register by phone, call: 703-733-0556