Snowmass Ophthalmology
REGISTRATION INFORMATION
Please complete the Registration Form below and fax to 772-287-0507 or e-mail to info@snowmasscme.com. Our customer service specialists will contact you regarding availability. Once availability is confirmed and payment has been processed, you will receive written confirmation of your registration.
Snowmass Ophthalmology Conference Registration Form
Name:_______________________________________________________________________________________
Address:__________________________________________________________________________________________
City:_________________________________________________State:___________ Zip Code:____________________
E-mail:
Home Phone:__________________________ Cell Phone:____________________________
Office Phone:__________________________ Fax: _________________________________
Preferred Method of contact: Home____ Cell____ Office____ Fax___
_______________________________________________________________________________________
Early Registration, before September 30, 2011: $375
Seminar Tuition: $475
Tuition includes daily continental breakfast and afternoon refreshments.
I am enclosing a check payable to Physicians Conference Assoc., Inc. in the amount of: $________________
or...
Please charge my credit card:
American Express ______ Discover _______
Master Card ___________ VISA ___________
Account No._________________________________________ Expiration Date ____________ Amount $_____________
Signature _________________________________________________________________________________________
Price Protection Guaranteed!
PLEASE NOTE: PCA strongly recommends independent vacation/trip cancellation insurance for plans including air travel. NO refunds can be made inside of the cancellation period.
Physicians Conference Association Inc.
509 SE Riverside Drive, Ste. 304 Stuart, FL 34994
Fax Form To: 772-287-0507 or mail to above address. For more information, call 772-287-1750
