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Practical Training in Vascular Interventions Practical Training in ...

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<strong>Practical</strong> <strong>Tra<strong>in</strong><strong>in</strong>g</strong> <strong>in</strong> <strong>Vascular</strong> <strong>Interventions</strong>featur<strong>in</strong>g “Hands-on” <strong>Tra<strong>in</strong><strong>in</strong>g</strong>July 15-19, 2013 & November 4-8, 2013• July Deadl<strong>in</strong>e: June 15, 2013• November Deadl<strong>in</strong>e: October 4, 20131 Personal Informationm MD m DO m Other__________________________________________________________________________Name____________________________________________________________________________________________Home Address____________________________________________________________________________________Home City & State/Prov<strong>in</strong>ce__________________________________________ Zip/Postal Code__________________Home Phone_______________________________________ Fax___________________________________________Email____________________________________________________________________________________________Office Address____________________________________________________________________________________Office City & State/Prov<strong>in</strong>ce__________________________________________ Zip/Postal Code__________________Office Phone_______________________________________ Fax___________________________________________Hospital Affiliation_________________________________________________________________________________Specialty_________________________________________________________________________________________Scrub Size m Small m Medium m Large m Extra LargeSpecial Needs_____________________________________________________________________________________Please <strong>in</strong>dicate special needs such as dietary restrictions.2 PaymentENROLLMENT IS LIMITED. YOU WILL BE NOTIFIED IF YOU ARE ACCEPTED FOR THIS COURSE.Full-Course with Hands-On Laboratory Sessions – $6000 for 5-day courseRegistrants will participate <strong>in</strong> all lectures and hands-on laboratory. Limited to 12 participants per course.Payment is required at time of registration.Please select course date you are attend<strong>in</strong>g: m July 15-19, 2013 m November 4-8, 2013Please enclose a check (U.S. currency) payable to the University of Michigan or pay by credit card below:m AmEx m Discover m MasterCard m VISATo Register:• By Fax (734) 764-1557• By Phone (734) 764-5297• By Mail RegistrarUniversity of Michigan, Conference Services1000 McIntyreAnn Arbor, Michigan 48105• Onl<strong>in</strong>e: http://www.hous<strong>in</strong>g.umich.edu/vascular-<strong>in</strong>terventionsAccount Number__________________________________________________________________________________Cardholder Name_____________________________________________________________ Exp. Date____________Signature____________________________________________________________________ Bill<strong>in</strong>g Zip ___________(not valid without signature)Cancellations: A special cancellation policy applies to this course due to the extensive preparation, high faculty-to-student ratio,limited enrollment and limited availability to substitute other participant’s for a week’s tra<strong>in</strong><strong>in</strong>g on short notice. Refund requestsmust be received <strong>in</strong> writ<strong>in</strong>g and are subject to a $50 adm<strong>in</strong>istrative fee. There are no refunds issued for participant cancellationsthirty days or less prior to the program.

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