1. Default Section

* 1. First and Last Name

* 2. Discipline

* 3. Are you a student?

* 4. Organization or School you are with

* 5. Your Address

* 6. City

* 7. Zipcode

* 8. Phone

* 9. email address

* 10. For continuing education purposes, what is your birth MONTH and DAY (year not needed).

* 11. What type of Continuing Education are you requesting?

* 12. What is your method of payment?
Note: $50 registration fee (or a PO) is due on our office by October 16th. Registration Fee for those registering after October 16th or at the door is $75. Registration fee includes parking, lunch and continuing education.

* 13. Please send payment to
DFW AHEC
5323 Harry Hines BLVD
Dallas, Texas 75390-8818

For information contact chong.lee@utsouthwestern.edu
214-648-8340

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