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COURSE
REGISTRATION-
Print out this page and fill out form and following mailing
insturctions at bottom of page.
"Injection
Snoreplasty — A Workshop"
Fee:
$250.00 / (No charge to Military Physicians) Advanced registration is mandatory.
Please
check one:
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Boston,
MA
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Saturday,
May 18, 2002
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8:30
am — 12:30 pm
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Registration
must be received by May 8, 2002
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Atlanta,
GA
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Saturday,
November 16, 2002
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8:30
am — 12:30 pm
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Registration
must be received by November 6, 2002
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San
Francisco, CA
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Saturday,
December 14, 2002
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8:30
am — 12:30 pm
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Registration
must be received by December
4, 2002
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Please
Print:
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Name:
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Address:
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City:
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State:
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Zip:
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Phone:
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Fax:
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Social
Security # (for CMEs):
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Yes
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No
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I will be staying at
the hotel on the nights of:
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Indicate
whether a stay at the hotel is needed, but please make your
own hotel reservation. When making our own hotel reservation
please mention the Injection Snoreplasty Workshop sponsored
by SNAP Laboratories and a discount rate will be granted.
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METHOD OF PAYMENT
Fee is $250.00
(No charge to Military Physicians). Please make check payable to SNAP Laboratories.
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Enclosed, please find my check in the amount of $_________
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Please charge $_________ to Visa or Mastercard (circle one)
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Printed Name:
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Signature:
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Acct #:
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Exp Date: |
ALL
REFUNDS MUST BE IN WRITING AND RECEIVED 3 WEEKS PRIOR TO THE
COURSE DATE. AFTER THIS DATE, NO REFUNDS ARE POSSIBLE.
Please
mail or fax registration & payment detail to:
SNAP
Laboratories
Re: Injection Snoreplasty Workshop
5210 Capitol Drive
Wheeling, IL 60090
Ph# 800.762.7786 ext. 201 / Fax# 847.465.3403
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