Unique Review Course- Registration Form Please check the course you wish to attend
JUNE 20 - JUNE 25, 2011 ( Course I)
JULY 11 - JULY 16, 2011 ( Course II)
Last Name :
First Name:Middle Name :
Address:
City:
State: Zip:
Telephone: home:
Telephone: office:
Specialty:
Year of Residency Completion:
Name of Medical School:
Hospitals of Training:
Date:
Signature:
Course Registration Fee… $1095.00
After filling in all information, please print, make a check
or money order for $1095.00
payable to Unique Review Course, Inc.
and mail with this form to:
Unique Review Course, Inc.
336 East Madison Avenue
Cresskill, New Jersey 07626 (Credit cards are not accepted)
For further information contact:
phone: 201-567-6133 / fax: 201-567-1729
In the event of a cancellation of either course,
Unique review course, Inc. will refund the full tuition fee but
will not be held liable for any other expenses. The Unique Review
Course, Inc. reserves the right to substitute teachers for either
course.
