Forms

Trauma and Critical Care Conference

To register for the San Juan Regional Medical Center Trauma and Critical Care Conference please complete the form below.
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Email
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Last Name
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First Name
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Address

ex. 111, Smith Street, apt. 111
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City
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State
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Zip Code
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Telephone Number

xxx-xxx-xxxx
Additional Attendees
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Conference Fees: $100
There will be a 3.5% transaction fee for those using credit cards
I will be paying by check.
Pay by check or PO: Please mail your check  with check payable to, SJRMC Trauma Conference:
Attn: Robbie Donald
San Juan Regional Medical Center AirCare and Trauma
801 West  Maple Street
Farmington, NM 87401


Enter your PO number in the text box below.
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I will be paying for this conference in advance with a credit card
Card Type
First Name
Last Name
Card Number
CVC Code
Expiration Date (month/year)
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Type of CE
Security Code
captcha
Type Security Code

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