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PCD Class Registration Form
Name: ____________________________________________
Address:__________________________________________
_________________________________________________
_________________________________________________
Occupation:_______________________________________
Phone:____________________________________________
E-mail:____________________________________________
Class Fee:
Full Professional ________ New Professional _______ Student _______
List classes by name:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Send form with a check payable to 'Michigan Psychoanalytic Council' to:
Ralph Hutchison, Ph.D., Registrar
7521 N. Telegraph, Suite #1
Newport, Michigan 48166
734.586.0031
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