Application for Continuing Medical Education Program

Name_______________________________________________

Address_____________________________________________

City________  State_____  Country _______  Zip Code______

Phone Number_______________    Cell___________________

Email_______________________________________________

The required fee for each 1.5 day program is $1200.00

(non-refundable) and must accompany the application.

Please make checks payable to:

International Research Foundation for RSD/CRPS

1910 E. Busch Boulevard

Tampa, FL  33612

Phone: 813 907-2312

    Anthony Kirkpatrick, MD, PhD

Tampa, Florida USA

Signature_________________________________    Date _______________