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Title*
Dr. Mr. Mrs. Ms.

First Name* (as it appears on your passport)

Last Name*(as it appears on your passport)

Would you like designations on your badge?*
Yes No

Date of birth of 1st passenger:*
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Golf Shirt Size for Delegates:
size small medium large x-large xx-large

Professional Degree:

Clinic Name:

How did you hear about this event?
Website Brochure FORUM WOM

Other:

Person who recommended you attend:

Address Line 1: *

Address Line 2:

City: *

Prov/State: *

Country: *

Postal/Zip Code: *

Phone: *

Fax:

Email: *

Partner Information

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Partner Program:
Yes No

Partner Title
Dr. Mr. Mrs. Ms.

Partner First Name (as it appears on their passport)

Partner Last Name (as it appears on their passport)

Date of birth for 2nd passenger:
Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Golf Shirt Size for Partner Program Participants:
size small medium large x-large xx-large

Will you be traveling with any other family or friends?

Yes If yes, their names:
No

Do either of you have any dietary requirements?
Yes If yes, please explain:
No

Will you be celebrating any anniversaries?
Yes If yes, the date:
No

Will you be celebrating any birthdays?
Yes If yes, the date:
No

Registration Rates

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Make your cabin selection from one of the sailings below
All Prices are in CAN$

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March 6-13, 2010 – Eastern Caribbean Psychiatry Update 2010
Accommodation Rates:*	Delegate	Companion
Non-Ocean View Stateroom	Please Call	FREE
Ocean View Stateroom	from $1799	FREE
Balcony Stateroom	from $2199	FREE
3rd/4th Guest in Stateroom	from $549
Fee **
Delegate (CPA Member)	$895
Delegate (Non Member)	$995
Delegate (Resident)	$795
Partner Program	$495
Cruise Taxes/Gratuities:
Per person	$269
Children 12 and under	$199
Payment Information:
Deposit	$800
***Pricing Subject to Availability and Change

Cancellation Fees:

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90+ days in advance	$0
89-65 days in advance	Deposit
65-45 days in advance	50%
45-0 days in advance	Non-Refundable

*SStateroom prices include all on board accommodation, meals, activities and events; and are cruise only. Luxury Suites including butler service are available upon request. Call for details.
**CPD Fees subject to 5% GST at time of Final Payment.
**CME Fees subject to 5% GST at time of Final Payment.
Final Payment is due December 14, 2009.
All funds stated in CAD dollars.
Cruise Connections CME reserves the right to change or cancel course content, speaker or topics for cause.

Call 1-888-523-3732

We cannot invoice for payment. Registration will not be completed without payment.

Credit Card Information:

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Total Deposit: *
Card Number: *
Cardholder's Name: *
Card Type: *	-Select a Card Type- American Express Master Card Visa Diners Club
Expiration Month: *	-Expiration Month- 01 02 03 04 05 06 07 08 09 10 11 12
Expiration Year: *	-Expiration Year- 08 09 10 11 12 13 14 15 16 17
Comments:
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I hereby authorize Cruise Connections Canada to charge the credit card provided for the fee indicated. I am aware that all charges are subject to applicable taxes.