Registration Form: CME Activity
Thank you for your interest in attending the CME to be held just before Konkani Sammelan 2016 in Atlanta.

Symposium Date: Friday July 1, 2016, 7:00 am – 2:00 pm EST
Symposium Venue: Atlanta Airport Marriott Gateway, 2020 Convention Center Concourse, Atlanta, GA 30337

Fees per Person:
Physicians requesting Credit hours $75
Physicians not requesting Credit hours / All others : $30

Please submit this form for every person in your party attending the CME.

Please send the check, payable to "North American Konkani Association (NAKA)" and mention “CME” in the memo field. You can send one check to cover the charges for all people in your party to the following address.

Konkani Sammelan 2016
Attention: Ganesh Kamath
1604 Lightfoot Circle
Marietta GA 30062

Konkani Sammelan Dates: July 1 to July 3, 2016 . Visit for more details.

Question? - Contact us via emailing us at <>

First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Contact Number *
Your answer
Email ID *
Your answer
Are you requesting CME Credit hours? *
Your Speciality
Your answer
Your Practice Status *
If you are not a Physician, please select "Not Applicable"
Mailing Address Line 1 *
Your answer
Mailing Address Line 2
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Country *
Your answer
Never submit passwords through Google Forms.
This form was created inside of North American Konkani Association. Report Abuse - Terms of Service