Philadelphia Spine Summit - Thomas Jefferson University

Philadelphia Spine Summit - Thomas Jefferson University

Register Now!
Philadelphia Spine Summit: Inaugural Meeting
On the campuses of Thomas Jefferson University and University of Pennsylvania
May 8-9, 2015
_____________________________________________________________________ Male  Female
Last Name
First Name
MI
____________________________________________________________________________
Title (Dr, Mr, Ms.)
Personal Title (II, Jr)
Degree
Specialty
_______________________________________________________________________________
Affiliation/Organization
Mailing Address
_______________________________________________________________________________
City
State
Zip
_______________________________________________________________________________
Telephone  Work  Home  Cell
Fax
Email
___ ____ ____ _____
Web ID (Please provide the last four digits of your Social Security Number as your Web ID. This will allow you to access your CME transcript at anytime after
the course.)
Optional Dinner - Friday, May 8, 2015: Would you be interested in attending a group dinner on Friday, May 8, 2015
after the conference? Please respond:
□Yes □No
(If there is enough interest, dinner will be confirmed and additional details will be available on the course website)
Please do not include me in upcoming events mailing lists.
Are you a Jefferson Alum?
If yes, what year? ____________________
*How did you hear about this event? ____________________________________________________
REGISTRATION FEES
Didactic Presentations
Friday, May 8, 2015
$250
Cadaver Laboratory
Saturday, May 9, 2015
$500
Both Days
$650
To register please use one of the following options:
Register Online: http://jeffline.jefferson.edu/jeffcme/SpineSummit/
Fax: You may fax this form with credit card payment to (215) 923-3212
Phone: For further information, please call the Office of CME at 1-888-JEFF-CME or 215-955-6992
Mail: Philadelphia Spine Summit - Office of CME; 1020 Locust Street, Suite M-5; Philadelphia, PA 19107
Payment: Please make check payable to Sidney Kimmel Medical College, Office of CME, or provide Credit Card
Information.
Do not send cash. Registration will not be processed unless full payment is received.
□ Check is enclosed.
Check Number: ___________
I hereby authorize use of my:
□
Amount $ _____________
□
Visa
Mastercard Amount $ _____________
Account Number: ______________________________________ Exp Date: ___________________
Billing Address (if different from above): ________________________________________________
If you have any special needs, please contact the CME Office by April 24, 2015 at 1-888-JEFF-CME or 215-955-6992.