05.08.2013 Views

CardiovasCular TopiCs at Johns hopkins - Hopkins CME Blog

CardiovasCular TopiCs at Johns hopkins - Hopkins CME Blog

CardiovasCular TopiCs at Johns hopkins - Hopkins CME Blog

SHOW MORE
SHOW LESS

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.

EGisTraTion ForM Course Number: 80022781<br />

The Nicholas Fortuin Cardiovascular Topics <strong>at</strong> <strong>Johns</strong> <strong>Hopkins</strong><br />

February 17 - 19, 2011<br />

To Register: Online: www.<strong>Hopkins</strong><strong>CME</strong>.edu By fax: (866) 510-7088<br />

By phone (credit card only): (410) 502-9636<br />

Or mail this form to the <strong>Johns</strong> <strong>Hopkins</strong> University, Office of Continuing Medical<br />

Educ<strong>at</strong>ion, P.O. Box 64128, Baltimore, Maryland 21264-4128. Include check payable<br />

to HOPKINS/80022781 or include credit card inform<strong>at</strong>ion below.<br />

PAYMENT MUST ACCOMPANY FORM TO CONFIRM YOUR REGISTRATION.<br />

Please type or print clearly:<br />

last name first name middle initial<br />

primary degree (for name badge) primary specialty<br />

preferred mailing address<br />

city st<strong>at</strong>e ZIP + 4 code country<br />

daytime telephone fax number<br />

e-mail / / / / / / / / / / / / / / / / / / / / / / / / / / /<br />

You will receive confirm<strong>at</strong>ion notice by e-mail if you provide your e-mail address.<br />

M Check here if you wish to receive e-mail and/or fax notices about upcoming <strong>CME</strong> activities.<br />

Wh<strong>at</strong> do you hope to learn by <strong>at</strong>tending this activity? _____________________<br />

Please notify us if you have any special needs. __________________________<br />

REGISTRATION FEES: EARLY-BIRD FEES<br />

POSTMARKED POSTMARKED<br />

BEFORE 12/31/10 AFTER 1/1/11<br />

M Physicians ..................................................................... $395 .....................$475<br />

M Residents*/Fellows*/Allied Health Professionals ....... $210 .................... $250<br />

*with verific<strong>at</strong>ion of st<strong>at</strong>us<br />

M †ACLS Course (Optional) ................................................ $130......................$140<br />

For registr<strong>at</strong>ions received after 5:00 p.m. EST on February 11, 2011, include a $50 l<strong>at</strong>e fee. On-site<br />

registr<strong>at</strong>ions are payable only by credit card.<br />

ACLS COURSE or MEET THE PROFESSOR SESSIONS:<br />

(Please select EITHER the ACLS course OR the Meet the Professor Sessions AND Clinical Problem<br />

Solving Symposium below.)<br />

M †ACLS Course: (Thursday and Friday with testing on Friday – required for certific<strong>at</strong>ion)<br />

OR<br />

M Meet The Professor Sessions/Clinical Problem-Solving Symposium (Thursday):<br />

Please indic<strong>at</strong>e your choice in order of preference (1 - 5). You will <strong>at</strong>tend two sessions. Every <strong>at</strong>tempt<br />

will be made to assign you your first and second choices.<br />

A. Prevention D. Electrophysiology<br />

B. Peripheral Arterial Disease E. Women’s Cardiovascular Health<br />

C. Echocardiography<br />

AND<br />

Group Symposium: (Friday – for those <strong>at</strong>tending the Thursday Meet the Professor Sessions)<br />

Payment Type:<br />

TOTAL AMOUNT ENCLOSED: $ __________<br />

JHU Faculty/Staff Only: Complete registr<strong>at</strong>ion form and return with appropri<strong>at</strong>e form below to O<strong>CME</strong>,<br />

Turner 20.<br />

M Internal Order Number: The ION D<strong>at</strong>a Request Form, can be found online <strong>at</strong><br />

http://www.<strong>hopkins</strong>cme.edu/pdfs/IonRequest.pdf.<br />

M Tuition Remission: To apply for TR, go to http://benefits.jhu.edu/EduBenefits/tuitionRemission.cfm.<br />

This is a non-credit professional development activity.<br />

M Check (See instructions on top of form.)<br />

M Credit Card: M VISA M MASTERCARD M DISCOVER M AMEX<br />

Card # - - - Exp. D<strong>at</strong>e ________<br />

Name on Card Sign<strong>at</strong>ure & D<strong>at</strong>e

Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!