Registration Form for
AO ASIF Foot and Ankle Course

March 5 - 8, 2003
Sun Valley Resort
Sun Valley, Idaho

(Please type or print clearly)

Course Name:

Name:

Degree(s):

PGY I II III IV V
Social Security Number (For documentation purposes only):

Guest's Name (if any):

Address:
Check one: Home Office

City:
 State:
 Zip:

Phone (Office):
 Phone (Home):
 Fax Number:
E-mail address:

Hospital Affiliation:

City:

Surgical Specialty:
Orthopaedic Plastic General
Other

Have you ever attended an AO ASIF Course? Yes No
If yes, when and where?:

Tuition Enclosed: $1,375.00

Applications will not be accepted unless the Course tuition fees and a completed Pre-Course Questionnaire are included with the registration form.

You have the option to print this form, complete and return with payment to:

AO North America
Department of Continuing Medical Education
Re: Sun Valley Foot and Ankle Course

1690 Russell Road
Paoli, PA 19301
Tel: (800) 769-1391/(610) 695-2459
Fax: (610) 695-2420

or you can complete and submit the form online.

Enclosed is my check for $ made payable to: AO ASIF Continuing Medical Education

Charge my credit card:

(American Express not accepted)

Exp.Date: Card Number:
Signature (if mailing or faxing form):

Do you have any special needs:


PRE-COURSE QUESTIONNAIRE-MUST BE COMPLETED FOR REGISTRATION FORMS TO BE PROCESSED

1. Years in practice or PGY __________

2. Private practice? Yes No

3. Are you considering Foot/Ankle surgical specialty as a career choice?

4. Percentage of practice dedicated to foot and ankle trauma surgery?
%.

5. What do you expect to learn from the upcoming AO Course? Please explain in as much detail as possible.

Please do not consider yourself registered for this course until written confirmation is received.

Please press this button
to submit your registration form:

Thank you.

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