NASBS

REGISTRATION FORM & INFORMATION SHEET

Registration: This course is open only to Senior Neurosurgical Residents and Head & Neck Fellows.  Registration is limited to the first 15 residents and 15 fellows. There is a $200.00 registration fee, which will cover meals, hotel, and 2.5 day lab. Participants are responsible for their flight and transportation to the hotel.

Hotel/meals: Hotel rooms will be provided for the nights of Friday, July 9th-Monday, July 12th.  Participants will be sharing a room with one other attendee.  Rooms will be assigned on an ad hoc basis.  If a room is required for Monday night, it will be provided at the participant's expense.  There will be a reception on Friday night from 6:00pm-8:00pm. All breakfasts and lunches will be provided for participants. There will be dinner for attendees on Saturday night. Attendees will have dinner on their own on Sunday evening.

Travel:  Air travel to and from New Orleans is the responsibility of the participant.  The program will conclude at 11:00 AM on Monday, July 12th. Do not make your travel plans prior to receiving an acceptance letter to the course from the NASBS office. The NASBS will provide shuttle transportation to the Louis Armstrong New Orleans International Airport (MSY) at 11:30AM on Monday, July 12th. (Note: All early departure transportation will be the responsibility of the individual resident/fellow)

Resident First Name
Resident Last Name
Program Information
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Program Coordinator Email
Organization/Institution
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Participant Information
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State	Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Africa Armed Forces Americas Armed Forces Canada Armed Forces Europe Armed Forces Middle East Armed Forces Pacific
ZIP Code
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Are you a Member of NASBS	Yes No
Gender	Male Female
Credit Card for Payment
Expiration Date	month: 01 02 03 04 05 06 07 08 09 10 11 12 year: 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
CVCC Amex: 4 digits on front V/MC: 3 digits on back

 

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