Full Name |
|
Street |
|
Apt,
Suite etc. |
|
City |
|
Zip |
|
Phone |
|
E-Mail Address |
|
| |
|
Please
check all that apply: |
Received
by Nov 17, 2005
|
On-Site
Payment
|
|
|
$75 |
$125 |
|
|
|
$40 |
$90 |
|
|
|
$35 |
$85 |
|
Nov
18 Dinner (Add $20) |
$20 |
$20 |
|
Special Dietary Requirement |
|
Apply for CME
|
$150
(14.5 Category 1 credits for physicians)
|
BRCH
available for Chemical Dependency Counselor and Prevention
Specialists.
Applications for Nursing and Social Work CEUs have been
made.
|
SESSION SELECTION
Please
check the box(s) to indicate the session(s) you wish to
attend. Priority placement will be given on a first-come,
first-served
basis.
|
|
|
|
|
|
| |
|
|
|
Payment
Method: Check or Money Order Only
Make check payable to: ACSC
|
Please mail
your check to:
Asian-American Community Service Council
c/o Sandy Lin, ASIA, Inc.
730 Carroll St.
Akron, OH 44304
|
| |
|
For
room reservations, please call Marriott Cleveland East
directly:1-800-533-0162
In order to get the group rate of $79 per night,
please mention
that
you
are attending the 2nd Asian American Health Conference
in Ohio. |
| |
|
