2 Day Live Surgery & Sales Building Workshop Registration

Seminar Date: Saturday, September 11, 2010 and Sunday, September 12, 2010

Fields marked with * are required.

First Name: *		Last Name: *
Office Address: *		Office Address (2):
City: *		State/ Zip: *
County: *		Office Telephone: *
Website: *		Office Fax: *
Personal Email: *		Primary Board: *
Medical License No: *		Secondary Board:

Travel Information

Arrival Date:		mm/dd/yyyy
Departure Date:		mm/dd/yyyy

Hotel Accommodations

We will reserve a hotel room at the Crowne Plaza. Hotel rate is $99.00 plus tax and will be guaranteed with your credit card.

Accommodations:	No Hotel Needed 2 Double Beds 1 King Bed
Days You Need a Reservation:
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Meals

All meals are included on the day of the workshop.

Meals You Will be Joining Us For: Breakfast Lunch Dinner
Diet Restrictions:

Live Surgery Workshop Fee: $1,950.00

Fee is non-refundable unless written cancellation is received at least two weeks prior to the Live Surgery Workshop date.

Seating for this Live Surgery Workshop is limited and available on a first-come, first-served basis. With this in mind, we may not be able to honor all physician requests.

Please refrain from making final travel arrangements until you receive a call from us to obtain payment information. If you have any questions, please call Lori Potts at (800) 344-1151.

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