Credit Application

To receive P.A.C.E. credit for attending the "HER-2 as a Target for the Adjuvant Treatment of Breast Cancer" PCR webcast, please complete the following form.

Fields marked with * are required.

First Name:*
Last Name:*
Address:*
City:*
State:*
Zip:*
Country:*
Phone:*
Email Address:*
Confirm Email Address:*

Institution:
ASCLS Member Number:
State License Number:
Web Address:

By completing this form, I attest that I participated in the full instructional time for the program.

You may also print this form and mail to:
Dane Garvin Ltd.
1909 Dewes Street, Suite 1E
Glenview, Illinois, USA 60025