Home > 2004 National Collaborative > Application Form |
We would be happy to discuss tailoring our offerings to your needs and what we can help you achieve. For more information call Ekta Chaudhry at 202-895-2634, or email [email protected].
Fax to: | (202) 966-5410 |
Mail to: | Center For Palliative Care Studies 4200 Wisconsin Avenue, NW Washington, DC 20016 Tel. (202) 895-2625 |
You may print this application form. Please complete it and return it to us via fax or surface mail.Please print or type:
Organization: | ___________________________________________________ |
Contact Name: | ___________________________________________________ |
Title: | ___________________________________________________ |
Address: | ___________________________________________________ |
City: | ___________________________________________________ |
State/Province: | ___________________________________________________ |
ZIP/Postal Code: | ___________________________________________________ |
Phone: | ___________________________________________________ |
Fax: | ___________________________________________________ |
Email: | ___________________________________________________ |
We wish to participate in the Third National Medicaring Quality Improvement Collaborative (MedQuIC) Organized by CPCS. | |
Signature: | ___________________________________________________ |
Title: | ___________________________________________________ (CEO, COO, VP for Medical Affairs, or equivalent must sign) |
On a separate sheet: