Name:                                                                                            Degree:                             

Specialty:     Otolaryngology-HNS       Neurosurgery      Other:                                     

Address:                                                                                           

                                                                                                        

City:                                 State                 Zip code:                     

Daytime Phone:                                          Fax:                                 

Email:                                               

For CME registration purposes, please supply either the last 5 digits of social security number or your
medical license number:                                             (Mandatory)

Make check payable to "UC Regents". In memo section, please state "2006 endoscopic skull base course". Residents will need a letter from their program Director or department chair verifying resident or fellow status.

Credit card payment:   Visa        Master Card      Discover  Discover        American Express    

Name on card:                                                        Signature                                                      

Card number:                                                          Expiration date:                           

Cancellations:   Cancellations received in writing before June 1, 2006 will be refunded less a $75 administrative fee.

Please mail form or FAX to:

Department of Otolaryngology-HNS University of California, Irvine Attn: Ellen Takahashi 101 The City Drive S., Bldg. 56 Ste 500 Orange, CA 92868-3201 FAX: (714) 456-5747 TEL: (714) 456-5753 Ellen Takahashi or Mary Evans Email: eatakaha@uci.edu Additional details including proposed agenda can be found at: http://www.ucihs.uci.edu/otohns/

The University of California, Irvine and Medical University of Graz in 2005 initiated an educational collaboration to promote international, interdisciplinary clinical exchange, and scientific research. The University of California Irvine, School of Medicine gratefully acknowledges the educational grants provided by Karl Storz Endoscopy-America, Inc., Arthrocare, Inc., GE Medical Inc., Medtronic Inc., and Intuitive Surgical Inc.