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33rd ANNUAL MEETING REGISTRATION

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33rd ANNUAL MEETING REGISTRATION Powered By Docstoc
					                               33rd ANNUAL MEETING REGISTRATION

                               June 21-23, 2007
                               The Canyons Resort
                               Park City, Utah
                                                        (Please print and complete)
Name
Institution
Address




Phone
Email

                                                                                             Number
                                                                                            Attending          Subtotal
Advance Registration Fee for Members* (includes all                            $395.00
meals)
Late/On-site Registration Fee for Members (includes all                        $425.00
meals)
Meal Plans for Guests
   Option 1: All Meals (2 breakfasts, 1 lunch, 2 dinners)                      $250.00
              Children ages 5-11                                                $75.00
   Option 2: Dinners only (Thursday and Friday)                                $170.00
              Children ages 5-11                                                $45.00
   Children less than age 5                                                        n/a

       Total Payment Enclosed (Make checks payable to ADMSEP): $
                             *Advance Registration forms must be received by May 15, 2007

Name(s) of Guest(s):
Please specify if you and/or guests would like vegetarian lunch/dinners:
Please return registration form with payment to:              ADMSEP
                                                              Attn: Gary L. Beck
                                                              982183 Nebraska Medical Center
                                                              Omaha, NE 68198-2183

The Chicago Medical School, Rosalind Franklin University of Medicine and Science, Office of Continuing Medical Education is
accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for
physicians. The Chicago Medical School will designate this educational activity for an estimated maximum of 10 credits toward
the AMA Physician’s Recognition Award. Each physician should claim only those hours that s/he actually spent in the activity.

				
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