REGISTRATION FORM

Administrators in Medicine (AIM)

National Organization for State Medical and Osteopathic Board Executives

AIM Institute: 2008 Certified Medical Board Investigator (CMBI) Training Program

 

Investigator Training Dates: July 8-10, 2008 - Page Down for Further Information

 

Las Vegas, Nevada

 

MEETING REGISTRATION FEE IS $750 PER PERSON

  •   Three-day training seminar - Limited to 40 attendees

         Please make checks payable to: Administrators in Medicine

         AIM Federal ID Number:  74-2329314                

         Send Check to the AIM Treasurer at this address: Randal C. Manning, AIM Treasurer, c/o Maine Board of Licensure in Medicine, 137 State House Station, Augusta, ME 04333 

Meeting Registration Fee Refunds:  All cancellations must be in writing.  Individuals who cancel more than 15 business days prior to the meeting are entitled to a refund of their registration fee, less a $30 processing charge. Cancellations made within 15 business days of the meeting are non-refundable.

Meeting Registration Fee - $750

Note the names of registrants covered by these fees and the total dollar amount submitted below

 

Total dollar amount submitted:  $_________________

LIST OF REGISTRANTS:

The first three lines of this information will be used for your name badge:

 

Name:  _____________________________________________________________________________________________________ 

 

Title: _______________________________________________________________________________________________________

 

Board/Organization:  ___________________________________________________________________________________________

 

Address: ____________________________________________________________________________________________________

 

City, State, Zip Code: __________________________________________________________________________________________

 

e-mail address: _______________________________________________________________________________________________

 

Telephone:____________________________________________________________________________________________________

 

Name:  _____________________________________________________________________________________________________ 

 

Title: _______________________________________________________________________________________________________

 

Board/Organization:  ___________________________________________________________________________________________

 

Address: ____________________________________________________________________________________________________

 

City, State, Zip Code: __________________________________________________________________________________________

 

e-mail address: _______________________________________________________________________________________________

 

Telephone:____________________________________________________________________________________________________

 

Name:  _____________________________________________________________________________________________________ 

 

Title: _______________________________________________________________________________________________________

 

Board/Organization:  ___________________________________________________________________________________________

 

Address: ____________________________________________________________________________________________________

 

City, State, Zip Code: __________________________________________________________________________________________

 

e-mail address: _______________________________________________________________________________________________

 

Telephone:____________________________________________________________________________________________________

 

Name:  _____________________________________________________________________________________________________ 

 

Title: _______________________________________________________________________________________________________

 

Board/Organization:  ___________________________________________________________________________________________

 

Address: ____________________________________________________________________________________________________

 

City, State, Zip Code: __________________________________________________________________________________________

 

e-mail address: _______________________________________________________________________________________________

 

Telephone:____________________________________________________________________________________________________

 

Name:  _____________________________________________________________________________________________________ 

 

Title: _______________________________________________________________________________________________________

 

Board/Organization:  ___________________________________________________________________________________________

 

Address: ____________________________________________________________________________________________________

 

City, State, Zip Code: __________________________________________________________________________________________

 

e-mail address: _______________________________________________________________________________________________

 

Telephone:____________________________________________________________________________________________________

 End of Registration Form