25th Annual Pittsburgh Schizophrenia Conference

If you are paying with a credit card you may register on-line or you can complete the form below and fax it to us at 412-802-6910.
If you are paying by check, please mail the form and the check to us.
Please make your check payable to:

OERP/WPIC, and mail it with this form to:

Attn: Maria Peňa-Jordan
Office of Education and Regional Programming
Western Psychiatric Institute and Clinic
4601 Baum Boulevard, Room 178

3811 O'Hara Street, Pittsburgh, PA 15213

Telephone: 412-802-6917 / Fax: 412-802-6910

Email: penajordanmi@upmc.edu

www.wpic.pitt.edu/oerp

25th Annual Schizophrenia Conference (MA78) [Deadline November 10, 2008]
Friday, November 21, 2008

Social Security Number (Last Five Digits Only):

Name (First, Last):

Institutional Affiliation:

Address:

City: State: Zip Code:

County:

Day Telephone: (______)

Fax Number : (______)

Specialty & Degree(s):

E-mail Address:

For continuing education please check:
[ ] NBCC Counselor - NBCC #

[ ]Nurse; [ ]Physician; [ ]Psychologist; [ ]Social Worker; [ ]CPRP; [ ]CRC; [ ]Educator (Act 48)

Tuition: $_______           Total Enclosed          Check#_______

Check [ ] VISA [ ] MasterCard [ ] AMEX [ ] Discover [ ] UPMC Account [ ]

To be completed by Credit Card Users ONLY:
Card Number:

Expiration Date:

Signature:

Security Code (3 digits from the back of the card):

To be completed for UPMC account transfers ONLY:
Business Unit & Account Number:

Administrator's Name:

Administrator's Signature:

Word Registration Form

The University of Pittsburgh, as an educational Institution and as an employer does not discriminate on the basis of race, color religion, ethnicity, national origin, age, sex, sexual orientation, or marital, veteran, or handicapped status. This is a commitment made by the University and is in accordance with federal, state and local laws and regulations. All relevant programs are administered by the Office of Affirmative Action, 901 William Pitt Union, University of Pittsburgh, Pittsburgh, PA 15260. Students, employees, or applicants should contact the Office of Affirmative Action immediately in all cases where discrimination is alleged. For more information call: (412) 648-7860.