NASBS News and Upcoming Events

Vol 12 No 1 Archive

REGISTRATION FORM
Please register early. The Annual Meeting registration fee covers all scientific sessions and social program except the Pre-Meeting Courses, which require additional registration fees.

Registration Fees - Annual Meeting	By 12/31/02	After 12/31/02	TOTAL
Physician-Member (Must be a member of NASBS, or other Skull Base Society)	$500.00	$575.00	$
Physician-Non-Member	$575.00	$650.00	$
Resident/Fellow* (Requires signature below)	$275.00*	$350.00*	$
Allied Health	$100.00	$100.00	$
Accompanying Person (Includes Social Program, does not attend meetings)	$250.00	$300.00	$
Registration Fees - Pre-Meeting Courses Please note: Enrollment in the following courses is limited. Register early to insure a space. Preference will be given to those also registered for the Annual Meeting.
Hands-On Practical Course
Physician	$950.00	$1,000.00	$
Resident/Fellow*	$850.00*	$900.00	$
Endoscopic Course: Hands-on Training
Physician	$300.00	$350.00	$
Resident/Fellow*	$200.00*	$250.00	$
TOTAL REGISTRATION FEES			$

Registrant's Name: ____________________________

Address: _____________________________________

Address: _____________________________________

City; State: ___________________________________

Country; ZIP/Postal Code: ______________________

Telephone: ___________________________________

FAX: ________________________________________

E-Mail: ______________________________________

*Program Director's Signature: ___________________
(Required for Residents/Fellows only)

Accompanying Person Name: ____________________

Registration fees may be paid with a personal or institutional check in US dollars payable to the NASBS or by credit card.
Registration to paid by:
Check: [ ] or
Credit Card: [ ]VISA [ ]Master Card [ ]AMEX

Name on Credit Card (please print): _______________

Card Number: _________________________________

Exp Date: ____________________________________

Credit card billing ZIP code: ____________________

Signature: ____________________________________


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

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