Registration Form for
AO ASIF Principles of Fracture Management

July 10 - 13, 2003
Hilton Columbus
Columbus, Ohio

(Please type or print clearly)

Course Name:

Name:

Degree(s):

Social Security Number (For documentation purposes only):

Guest's Name (if any):

Home Address (Street address only - No P.O. Box):

City:
 State:
 Zip:

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

Residency Program:

PGY: I II III IV V Fellow

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

Do you have any special needs:


Tuition.....$965.00

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

AO North America Continuing Medical Education
Re: Columbus Principles of Fracture Management 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):

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

1. Are you considering trauma as a career choice in orthopaedics? Yes No

2. As a participant, please check off what you expect to learn from the Course.

Principles of Fracture Management Basic knowledge of operative treatment
Trauma principles and techniques Internal and external fixation
Preoperative planning methods Reduction and stabilization techniques
AO concepts and procedures Other

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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