2012 Meeting Registration Form


  CONTACT INFORMATION
* Required
*First Name: *Last Name: *Degree:
*Address:
*City:
*State:
*Zip code:
*Country:
*Phone: Fax:
*E-mail:

Special Dietary Request:
(please select one)
Kosher   Vegetarian   No preference

*Subspecialty:
Cataract surgery
Contact lenses
Cornea/External disease
General ophthalmology
Glaucoma
Retina		 Neurosciences
Oculoplastics
Optics
Pediatrics/Strabismus
Refractive surgery

 
*How did you hear about the meeting?
 Multiple selections allowed
Ocular Surgery News Print Advertisement
OSN SuperSite and/or News Wire
OSN Exhibit Booth
E-mail
Letter
Brochure
Post Card
Flyer
Phone
Word of Mouth
Internet Search
Other
Priority Code
Please enter the priority code found on the lower right-hand corner
of your brochure registration form or other marketing materials.

CME Activity Request

Yes, I would like the opportunity to earn CME credits through future activities jointly
sponsored by Ocular Surgery News and Vindico Medical Education.

  *REGISTRATION TYPE

Register early and save $100!
Physician
Preregistration...................................$860
Onsite Registration............................$960
Resident/Fellow*
Preregistration...................................$525
Onsite Registration............................$625
  *Must submit letter of verification to qualify for this rate.

Welcome Reception Guest(s)
Social Event Fee.........................$50
Allows guest(s) to attend the welcome reception
          Name of Guest(s):

   *BILLING INFORMATION
   (check if the same as Contact Information at top of page)
*Accountholder's Name:
*Statement Mailing Address:
*City:
*State/Province:
*Country:
*Postal Code:



For more information, contact Meeting Registration by e-mail: MeetingRegistration@SlackInc.com

Federal ID # 22-3014562

Cancellations: Requests for refunds must be submitted in writing by May 26, 2012. There will be a $200 service charge retained for all refund requests. Requests received after this date will be ineligible for refunds.