Registration Form for
AO ASIF Advanced Symposium
Solutions Course for Fracture Fixation Problems

May 1-4, 2003
The Plaza Hotel
New York, New York

(Please type or print clearly)

Course Name:

Name:

Degree(s):

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:

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

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 Continuing Medical Education
Re: Solutions Course for Fracture Fixation Problems
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. Year in practice?
Private Practice Yes No Other:

2. Percentage of practice dedicated to trauma surgery? %

3. How many/how often are failed fixation cases referred to you?
OR Is there someone within your community/area to whom you can refer difficult cases?
Yes No

4. What do you expect to learn from the upcoming Symposium? What do you expect to learn that would benefit you in your practice?
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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