AO ASIF Podiatric Comprehensive Course Registration Form

October 7 - 10, 1999
Adam's Mark Hotel
Charlotte, North Carolina

Please complete this form in it's entirety to register.

You have the option to print this form, complete and return to:
AO ASIF Continuing Education
Re: Charlotte Podiatric Comprehensive Course
P.O. Box 1766
Paoli, PA 19301-0800
Tel: (800) 769-1391/Fax: (610) 251-5039
or you can complete this form and submit online using a credit card:

Course Name:

Course Location and Date:

Name:

Degree(s):

Social Security Number:
(For documentation process only)

Guest's Name (if any):

Mailing address:

Home Phone:

Work Phone:

E-mail address:

Fax Number:

Hospital Affiliation and City:

Tuition Enclosed:
$995.00/FULL
$875.00/RESIDENT

Have you ever attended an AO ASIF Course:
Yes
No
If so, when and where:

Do you have any special needs?

APPLICATIONS WILL NOT BE ACCEPTED UNLESS TUITION FEES ARE INCLUDED WITH THE REGISTRATION FORM.
Please make checks payable to:
"AO ASIF CONTINUING EDUCATION"
If you need further assistance, please email delonel@aona.com
Payment method:
Exp. Date: Card Number:
Signature (if mailing or faxing form):
Do you have any special needs:

Please press this button
to submit your registration form:

Thank you.