Unique Review Course for Internal Medicine
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Unique Review Course - Registration Form

June 19 to June 24, 2017

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.

 
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