Name And Professional Information

First Name*

Initial

Last Name*

Preferred Name

Degree*
MDDODDSPANPOther

State Issuing Medical License*

State Medical License Number*

Specialty 1*

Specialty 2

Year completed the MAFP Course*

Contact Information

Primary 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.

Tuition*

Indicate course(s) you are applying to:*

Graduate Refresher Course Only: $1250($1400 after August 1)CSA and Graduate Refresher Course: $1700($1900 after August 1)

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 9:00 AM and 2:00 PM Pacific Time or fax to 510-649-8692

All training activities will take place at the Edward Hotel Chicago (Rosemont, IL) where a group rate of $112 (plus 14% occupancy tax) has been arranged. Reservation information will be provided upon acceptance to the course.
For additional information about this course, call 510-649-8488 or e-mail mafp@hmieducation.com.