Name And Professional Information

First Name*

Middle Initial

Preferred Name*

Last Name*

Pronouns*
She/Her/HersHe/Him/HisThey/Them/TheirsOtherPrefer not to respond

Date of Birth*
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Degree*
MDDODDSPANPOther

State Issuing Medical License*

Medical License Number*

Specialty 1*

Specialty 2

Contact Information

Primary Email*

Military personnel and government employees must list a non-work email address for their primary email.

Work Email

Home Address:

Street*

Street address only, no P.O. boxes.

City*

State*

Zip*

Personal Phone*

Please use the format 555-555-5555 for US phone numbers.

Work Phone

Please use the format 555-555-5555 for US phone numbers.

Military Personnel & Government Employee Applicants Only

Service Branch
—Please choose an option—Air ForceArmyMarinesNavyVACivilian EmployeeOther

Military Rank

Date of end of obligated service
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Tuition*

300-Hour CME course: $12,650 by credit card, $12,350 by check$500 late enrollment fee after Feb 6.Full-time Resident or Fellow rate (self-pay): $10,550 by credit card, $10,250 by checkResident/Fellow rate only available if applicant is self-paying. Tuition paid by Residency/Fellowship Program is not eligible for discounted rate. $500 late enrollment fee after Feb 6.

Indicate method of payment:*

CheckPreferred - Payable to Helms Medical Institute, 2520 Milvia Street, Berkeley, CA 94704Credit Card - onlinePay online at https://mkt.com/hmiCredit Card - by phoneCall 510-649-8488 between 10am and 3pm Pacific Time or fax to 510-649-86923rd Party PaymentSpecify:

All training activities will take place at the Bolger Conference Center in Potomac, Maryland (just outside of Washington D.C.). You are requested to lodge at the hotel where a group rate has been arranged ($182-$222 per night + tax). A conference day use fee of $89 per day is required of participants who choose to stay elsewhere or room with another course participant.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com. Once you have submitted this online application you will receive a confirmation email.