AO ASIF Comprehensive and Interactive Spine Course Registration Form

November 11 - 14, 1999
Tucker's Town, Bermuda

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: Bermuda Comprehensive and Interactive Spine 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:


Name:


Degree(s):


Social Security Number:

Guest's Name (if any):

Mailing address:
Home Phone:

Work Phone:

E-mail address:

Hospital Affiliation:

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

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:

PRE-COURSE QUESTIONNAIRE-MUST BE COMPLETED FOR REGISTRATION FORMS TO BE PROCESSED


1. How many years in practice:

2. Private Practice:
Yes>
No>
If no, please specify:

3. Percentage of practice devoted to spine surgery:

4. Are you considering spine surgery as a career choice:
Yes
No
4. What do you expect to learn from the upcoming AO ASIF Comprehensive spine course? What do you expect to learn that would benefit you in your practice?
Please explain in as much detail as possible:

Please press this button
to submit your registration form:

Thank you.