COURSE APPLICATION FOR:

THE ROBERT F. BORKENSTEIN COURSE ON THE EFFECTS OF DRUGS ON HUMAN PERFORMANCE AND BEHAVIOR
October 1st - 5th, 2012

Note that this year we are taking the Drug Course on-the-road to the Chemical Heritage Foundation in Philadelphia! Don't miss this outstanding venue in old city Philadelphia, with multiple nearby hotels and restaurants.

TUITION:  Tuition is $1500.00. PAYMENT FOR TUITION IS DUE PRIOR TO THE COURSE. Click here for payment information.

Please complete the following application form; we will review it for acceptance and then will notify you soon regarding your application status and payment details.

Title (please check one)		Mr. Mrs. Ms. Miss
Name
		(exactly as you want it to appear on your certificate)
Job Title
Organization
Address of Organization
City
State
Zip
Phone
Fax
Email