Canadian Bladder Cancer Forum 2023

Full Name*

PrefixFirst NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Hospital Affiliation*

Specialty*

Royal College ID Number

Dietary restrictions or other

*

Physicians ($75+tax)

$75.00CAD

Residents/Nurses/Researchers($50+tax)

$50.00CAD

Bladder Cancer Canada volunteer($0)

$ Free CAD

Industry($300+tax)

$300.00CAD

Enter coupon

Subtotal

$0.00CAD

Tax

$0.00CAD

Total

$0.00CAD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Confirmation of Registration*

I hereby confirm my registration

Do you give consent to CUA sharing your name and location ONLY to program sponsors?*

YesNo

Please verify that you are human*

Meeting Co-Chairs:

Madhuri Koti, Queen’s Cancer Research Institute

Srikala Sridhar, UHN, Department of Medical Oncology

March 31-April 1

Kingston, ON

Contact: Nadia.pace@cua.org
Accredited for Section 1 Group Learning Credits.

Canadian Bladder Cancer Forum 2023

Meeting Co-Chairs:

Madhuri Koti, Queen’s Cancer Research Institute

Srikala Sridhar, UHN, Department of Medical Oncology

March 31-April 1

Kingston, ON

Contact: Nadia.pace@cua.org Accredited for Section 1 Group Learning Credits.

Contact: Nadia.pace@cua.org
Accredited for Section 1 Group Learning Credits.