Physician Self-Study Packet Request Form

Please complete this form. Required fields are marked with an '*'. There is a $100 fee for this packet, which includes all copyrighted materials, a tear-resistant pocket guide, test and evaluation materials, processing the completed test, and issuance of a CME/COE certificate.  Your packet will be mailed as soon as payment is received.

Name: *    Discipline:
                       (this package is intended for individuals who are eligible for CME/COE continuing education credits)

Address: * 

City: *        , State:   Zip Code:

Email:      

Phone:    

Comments:

                [Please type your comments here.]

How did you hear about this program?

Registration fee is due at time of packet request and may be paid by check or credit card.  Please select your payment method:
     I'll pay using PayPal  (please click on the Pay with PayPal button after clicking on 'Submit')
     I'll call 1-800-438-5963 and pay using my Visa/Mastercard
     I'll mail my check made payable to "Maine Hospice Council" to PO Box 2239, Augusta, ME 04338-2239

       Please add me to your mailing list

Thank you.