Registration

	2005 Meeting Series 2 Curriculum Tracks: Physician Program System Operator Program

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SYSTEM OPERATORS
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Highlights
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Registration

Personal Information

First Name:	Last Name:	Degree:
Address:
City:	State/Province:
Country:	Postal Code:
Telephone:	Fax:
E-mail:	Special Notes:

Where did you hear about this meeting?* * Multiple selections allowed		If "Other", please let us know where:
Primary subspecialty: Cataract/IOL Glaucoma Refractive Ret/Vit Pediatric

Registration Type

	A. Physician	US$ 100
	B. System Operator	US$ 40

Registraton City

	Dallas, TX June 28		Chicago, IL September 20
	New York City, NY July 26		Denver, CO September 27
	McLean, VA August 30		Atlanta, GA November 8
			Los Angeles, CA December 6

Payment Information

Credit Card Type:	(payable in US funds drawn on a US bank)
Account Number:	Security Code
Name on Credit Card:	(as shown on the card)
Expiration Date:
Billing Information (check if the same as Personal Information at top of page)
Accountholder's name:	(as shown on the statement)
Statement Mailing Address:
City:
State/Province:
Country:
Postal Code:

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Contact Information

You can register online using the REGISTER button above, or print the form out and ...

FAX THE FORM:	1-856-251-0278
MAIL THE FORM:	Registration Manager Optimizing Outcomes in a CustomVue-Driven Practice 6900 Grove Road Thorofare, NJ 08086-9447
REGISTER VIA TELEPHONE:	Toll-free: 1-877-307-5225 Ext. 219 or 1-856-848-1000 Ext. 219 (Outside the U.S.)
REGISTER VIA E-MAIL:	meetingregistration@slackinc.com
OFFICE HOURS:	8:00 AM - 4:30 PM, Monday - Friday, EST

Requests for refunds must be submitted in writing and received prior to the meeting date. A $25 service charge will be applied to all refunds.

ADA COMPLIANCE: In compliance with the Americans with Disabilities Act of 1990, we will make all reasonable efforts to accommodate persons with disabilities. Please call with your requests.

Federal ID # 22-301-44562