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Southeast MedWAR
CME Credit Application Form

To register to receive CME Credit for participation in the Southeast MedWAR Race, please fill out the form below. You will sign it at check-in. Include the type of CME credit you are interested in and your SSN (required). The information will be kept confidential and only used to obtain your CME credit. To obtain CME credit, you must register in advance. You cannot register for CME credit on Race Day.

In addition, there is a $35 fee which can be paid online. You will be taken to the site upon completion of the form. You may use credit cards online through PayPal without having a PayPal account. We cannot accept credit cards over the phone or in person at this time.

First Name*: Last Name*:

Affiliation: (School/Hospital/Organization/etc.)

Occupation*: If Other:

Type of CME Credit*:

Social Security Number*:

Email*:

Street Address*:
City*: State/Province*:
Country*: If other, Country:
Zipcode*:
Phone Number:

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