Connecticut Ear, Nose and Throat Society Annual Meeting Thursday April 9, 2015 The Aqua Turf Club, 556 Mulberry Street, Plantsville, Connecticut Physician Registration Form NAME:_________________________________________________________________ (please print) ADDRESS:______________________________________________________________ (please print) CITY:_____________________________________STATE:______ ZIP:_____________ TELEPHONE:___________________________________________________________ EMAIL ADDRESS:________________________________________________________ ______ Yes, I am planning on attending the November 14, 2014 Annual Education Program ______ No, I am unable to attend the November 14, 2014 Annual Education Program Member Physician Fee: $100.00 Non-Member Fee: $200.00 Non-M.D,/Office Personnel: $ 75.00 Residents: Complimentary (please make checks payable to CT ENT Society) Please mail this form with your payment to: CT ENT Society, P.O. Box 863, Litchfield, CT 06759 Fax: 860-567-3591 This activity has been planned and implemented in accordance with the Essentials and Standards of the Connecticut State Medical Society through the joint sponsorship of CSEP and The Connecticut ENT Society. CSEP is accredited by the CSMS to provide continuing medical education for physicians. CSEP designates this educational activity for a maximum of 6.0 credit hours in category I credit toward the AMA Physicians Recognition Award. Each physician should claim only those hours of credit that he/she spent in the activity. (This form may be copied for additional registrations) ************************************************************************ (for CT ENT office use) Check # ___________ Received __________ Amount __________ DEADLINE FOR REGISTRATION IS March 30, 2015 Contact Debbie Osborn at [email protected] or cell 860-459-4377