NASBS News and Upcoming Events

Vol 10 No 1 Archive

12th Annual Meeting

Annual Meeting - Meeting Registration Form

REGISTRATION FORM

Please register early for the 12th Annual Meeting. The Annual Meeting registration fee covers all scientific sessions and social program except the Pre-Meeting Workshop and Practical Course, which require additional registration fees.

Registration Fees - Annual Meeting TOTAL

Physician-Member $575.00 $ __________

(Must be a member of NASBS, or other _______________ Skull Base Society)

Physician-Non-Member 625.00 $ __________

Resident/Fellow * (Requires signature below) 350.00* $ __________

Allied Health 300.00 $ __________

Accompanying Person (Includes Social Program, does not attend meetings) 200.00 $ __________

Registration Fees - Pre-Meeting Courses

Please note: Enrollment in the following courses is limited. Register early to insure a space.

Pre-Meeting Workshop (Wed-Thu, Feb 28-March 1) - Physician 1,000.00

Pre-Meeting Workshop (Wed-Thu, Feb 28-March 1) - Resident/Fellow* 800.00* $ __________

Pre-Meeting Practical Course (Fri, March 2) - Physician 500.00

Pre-Meeting Practical Course (Fri, March 2) - Resident/Fellow* 400.00* $ __________

BOTH Pre-Meeting Workshop and Practical Course - Physician 1,400.00

BOTH Pre-Meeting Workshop and Practical Course - Resident/Fellow* 1,100.00* $ __________

TOTAL REGISTRATION FEES $ __________

Registration fees may be paid with a personal or institutional check in US dollars payable to the North American Skull Base Society or by credit card.

Credit Card: G VISA G Master Card G AMEX Name on Credit Card (please print): ___________________________

Card Number: __________________________________________ Exp Date: _______ Signature: ______________________

Name: _________________________________________________________________________________________________

Address: _______________________________________________________________________________________________

_______________________________________________________________________________________________________

City: ______________________________ State: ______ Country: __________________ ZIP/Postal Code:______________

Telephone: _______________________ FAX: ______________________ E-Mail: __________________________________

*Program Director's Signature Required for Residents/Fellows only: _____________________________________________

Accompanying Person Name: _____________________________________________________________________________

Please mail payment and completed registration form to:

North American Skull Base Society

4815 Rugby Avenue, Suite 203

Bethesda, Maryland 20814-3033

301-654-6802

FAX 301-718-8692

Special Assistance: If you have any disability for which you require special assistance while attending this meeting, please contact NASBS at 301-654-6802.