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Registration Fees: |
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Symposium |
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The
registration fee for the symposium is $300 for Physicians and $200 for
non-physicians. The fee includes continental breakfasts on Saturday and
Sunday, refreshment breaks each day, dinner symposium on Friday night,
reception Saturday night and a syllabus. |
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Hands-On-Workshop |
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The registration
fee for the optional Hands-On-Ultrasound Workshop for IMT on Saturday
afternoon is $125. |
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Guest Fee |
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For $125 per
person, guests may attend the continental breakfasts on Saturday and Sunday,
dinner symposium on Friday night, lunch on Saturday and the reception
Saturday night. |
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Cancellation Policy |
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In the event you
must cancel, the registration fee less a $50 administrative charge
will be refunded if notice of cancellation is recieved in writing prior to
September 13, 2002. Refunds will not be given after this date. |
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Registration Form (Please Print or Type) |
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| Name |
________________________________________________________________________________________ |
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(Please write as preferred for nametag and certificate) |
| Degree |
_______________________________________ |
Social Security or AMA # |
______ - ______ -
__________ |
|
Profession |
________________________________________________________________________________________ |
| Address |
________________________________________________________________________________________ |
| City |
______________ |
State |
__________________ |
Zip |
___________ |
| Daytime
Phone |
______________ |
Fax |
__________________ |
Email |
___________ |
|
Physician Registration ($300) |
__________________________ |
Non-Physician Registration ($200) |
____________________________ |
|
Optional IMT Workshop ($125) |
__________________________ |
Guest (s) ($125 each) |
____________________________ |
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Make check Payable to the: |
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North Carolina Stroke Association |
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P.O. Box 571002 |
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Winston Salem, NC
27157-1002 |
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Payment by Credit
Card |
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Complete the credit card information then fax your registration
to (336) 716 9519 or mail to the above address. |
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| Visa |
______________________ |
MasterCard |
____________________ |
| Card
# |
________________________________________________ |
Expiration |
________________________________________ |
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Signature |
_______________________________________________________________________________________________________ |
| Name
on Card |
_______________________________________________________________________________________________________ |
| |
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For Office Use
Only |
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Auth/Check # |
__________________________________________________________________________________________________ |
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Amount |
__________________________________________________________ |
Date |
___________________________________ |
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