Please Print or Type
Name __________________________________________
(Last) (First)
Medical Profession: MD DO PA PT PTA OTR ATC
(Circle Degree)
Home Address __________________________________
__________________________________
Home Phone ( ) ___________________________
E-Mail _______________________________________
Employer _______________________________________
Work Address ___________________________________
___________________________________
Work Phone ( ) __________________________
Registration Fee: $ 595
$650 if received less than 14 days
prior to the course.
Make Check Payable To: American BackPain Center
Check & Registration To: American BackPain Center PO Box 101
Anchorville, Michigan 48004
If you prefer to register by mail or fax, copy the registration form below, fill it out and mail to our address listed at the bottom of this form, or fax to us at (586) 716-8852
