Contact Name/Title:
Practice Name:
Address:
City:	State:		Zip:
Phone:		Fax:
E-mail:
Please list the Seminar City and Dates you wish to attend:  __________________________________________
Please list the attendees with First and Last names:
Attendee #   1:                                                                         Fri / Sat / Sun ?
Attendee #   2:                                                                         Fri / Sat / Sun ?
Attendee #   3:                                                                         Fri / Sat / Sun ?
Attendee #   4:                                                                         Fri / Sat / Sun ?
Attendee #   5:                                                                         Fri / Sat / Sun ?
Attendee #   6:                                                                         Fri / Sat / Sun ?
Attendee #   7:                                                                         Fri / Sat / Sun ?
Attendee #   8:                                                                         Fri / Sat / Sun ?
Attendee #   9:                                                                         Fri / Sat / Sun ?
Attendee #10:                                                                         Fri / Sat / Sun ?
REGISTER BY EARLY BIRD DEADLINE* AND SAVE!  “We highly recommend attending all sessions!”
PLEASE PRINT LEGIBLY
Please make checks payable to Clinicworks, Inc.  Mail check payments to: Paul M. Schmitz, DVM                                                   1616 S. Beech Ave.                                                    Broken Arrow, OK 74012 Please Check here if paying by mailed Check ____  --> Sorry, checks not accepted after the Early Bird Deadline as listed above
Major Credit Cards Accepted Online or via Phone Virtual Terminal  Check here ___ if registering and paying "online".
Additional Comments or Questions:_________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________
Cancellation Policy: You may cancel your registration up to 10 days before the seminar.  Your registration fee will be refunded, less a $25.00 service charge, per day, per person canceled.  If you need to cancel less than 5 days prior to the seminar, you may:  1) send a substitute from your practice or 2) transfer your registration fee to another Clinicworks AVImark Seminar of your choice within 12 months.    --> Sorry, checks not accepted after the Early Bird Deadline as listed above