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University of Pikeville

KYCOM CME & Alumni Event

	Date of Event:September 27 - 29, 2024 Event Fee:At this time the fee for physician's is set at $350 per person, $425 if after September 13th. Cancellation fee is $50
	Please fill out the below fields to purchase tickets for KYCOM CME & Alumni Event.
*	Full Name:
*	Physician Type (MD, DO, other):
*	DO/MD ID Number:
	AOA/AMA ID Number :
*	Mailing Address:
*	City State Zip:	, ,
	KYCOM Alumni Class of:
*	Phone (Work):	( ) -
	Phone (Cell):	( ) -
*	Email Address:
	Events planning to attend:
	KYCOM Primary Care CME Program
	Founders Dinner - No Cost. (Number of Tickets Needed)
	KYCOM Alumni Reception, number of tickets needed (no charge)
*	Number of Tickets Needed:	cde-Numbof-14

*Payment Amount

$ .

Payment Options:

Debit Card

Debit Card

E-Check

Credit Card

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