Herewith my check payable to
Otolaryngology Updates for participation in the
Clinical
Refresher Course.
Date stamped
2007
2008
❑
Course Registration:
Practicing Physician
❑ $625
❑ $675
Resident or Full-Time Military
❑ $525
❑ $575
(with
letter from Chief of Service)
Nurse or Ancillary
❑ $350
❑ $400
❑
Spouse Registration:
Reception: Wine & Hors d’oeuvres
❑ $60
4 Continental Breakfasts
❑ $88
Name of Spouse/Associate ____________________________
Please Type or Print Clearly
Name:
First__________________
Last________________________
Address ___________________________________________
City______________________State________ Zip_________
Tel:_____________________Fax:______________________
Email: ____________________________________________
Please return this form with your check or credit card
information to:
Ellen Takahashi
Bldg 56, Head &
Neck Surgery
101 City Drive,
Orange, CA, 92868
Credit Card Information:
Visa or MasterCard only
Visa
❑
Master Card
❑
Exp. Date _________________ Card number
_______________________________________
Authorizing signature ________________________________
Refund Policy:
There will be a $60 service charge for all
cancellations.
Sponsored by the Irvine Head and Neck Research Foundation
and the
Otolaryngology Research Foundation