Contact Dermatitis 2004 – Blending Science with Best Practice

Information Request/Presentation Submission Form

Submission of your contact information below will send an E-mail to the organizing committee, who will compile a mailing list to distribute further information. It is not our intention to release this information for any other purpose.

*Name
*E-mail address
Affiliation
Mailing Address
Telephone
Fax
	*Required information
Which meeting are you interested in attending (see Meeting Registration menu)?
Both ECDRG and ACDS meetings
Only ECDRG meeting
Only ACDS meeting
Will you be submitting a title for presentation? If so, list the title here:
Participation at social events will be limited to the first 100 registrants and will be on a space available basis thereafter. If you intend to have guests at the social events, the guests will have to purchase separate social event tickets. Please list number of guests:
If you are a research fellow or resident in training, are you requesting that the registration fee be waived? [Letter from training program required]
Yes
No
If a research fellow or resident, do you want your presentation to be judged for the Young Investigator's Award?
Yes
No