Club Members Registration Form

Presidents & Ambassadors Club Members ONLY!

Winter 2012 Seminars

Please indicate which seminar(s) you plan to attend:

                        Decompression, February 23, Novi  

Modalities, February 25, Grand Rapids

EHR, March 3, Sterling Heights

Insurance, March 15, Southfield

Name
Address
City   State   Zip Code
Phone    Email

I am a member of:
Presidents Club    Ambassadors Club    Ambassadors Club Non-DC Staff

Total Number of Attendees

Name(s) of Attendees: