Annual Function

November 10-12, 2000

At the Muskoka Sands Resort and Conference Centre (Map)

1-800-461-0236

ON-LINE REGISTRATION FORM

REGISTRATION FEE

Active Member*            No Charge

Non-Active Member    $150.00/Family

Guest                             $100.00/Guest

CME FEE                     $15.00 per member

*Active members are those who have paid their membership dues

 

Please register by October 27, 2000

Registration fee will increase after the deadline

Cheque is payable to NIMDAC. Mail the cheque and registration form to

Dr. Umesh Jain

3 Cortleigh Court

Richmond Hill, Ontario L4B 3G9

Tel: 905 780 9499/ 416 767 0995

Fax: 416 767 0992

 

 

ON-LINE REGISTRATION FORM

 

NAME PARTICIPATION ACTIVITY

Doctor's :

Participating
Spouse  

Participating
Child #1 

Participating
Child #2 

Participating
Child #3 

Participating
Child #4 

Participating

Any other information