School of Medicine

Medical Alumni Board Meeting

som-board-meeting.jpg

Medical Alumni Board Meeting

I plan to attend:*
 
First Name*    
Last Name* 
Address
City, State, Zip Code     -
Phone*() - x
Email* 

Dinner Registration

I plan to attend the dinner ($50 per person):*
 
Total Number Attending Dinner:     Cost:
Dinner Guest Name
Please list any accessibility resources
(e.g. sign language interpreters, wheelchair
access, dietary, etc.) you may
require during this event.

Credit Card Processing

Card Holder Name*
Card Type*
Credit Card Number*
Credit Card Expiration Date*
Credit Card CVV Number*
Located on the back of the card