AO ASIF Nursing Continuing Education
Team Approach to the Operative Management
of the Spinal Surgery Patient Registration Form

Please do not consider yourself registered for this course until written confirmation is received. Course Name:

Enclosed is my check payable to:
AO ASIF CONTINUING EDUCATION

Please charge my credit card:

Master CardVISA Exp. Date: Card Number:
Signature (Signature of card holder required, if faxing or mailing form):


Name:
(as it should appear on your certificate)


Credentials:
(i.e., RN, CST, etc.)


Social Security No.:
(used for identification purposes only)


Home address:


City:


State:


Zip:

Home Phone:


Office Phone:


Office Fax Number:

Name and City of Hospital:
(no initials please)


Sales Consultant's Name:

• Registration is required in advance and is not accepted unless accompanied by the $125.00 tuition fee.
• Phone-in registrations cannot be accepted.
• Please do not consider yourself registered for this course until written confirmation is received.
• Registration deadline is June 20, 2003.