International College of Angiology

International College of Angiology Member, Council for International Organizations of Medical Sciences (CIOMS) EXECUTIVE OFFICE: 5 DAREMY COURT • NESCONSET, NEW YORK 11767-1547 631.366.1429 • FAX: 631.366.3609 • EMAIL: [email protected]

John B. Chang, MD, FICA, FACS, Program Chairman Takao Ohki, MD, PhD, Regional Organizing Chairman 50th Golden Anniversary Congress ICA’2008 EGISTRATION ORM R F Jikei University School of Medicine • Tokyo, Japan July 20th – 23rd, 2008

(Please Print) MD/MBBS/RN, RVT, PA (Family Name) (First Name) (MI) Registrant

Dr./Prof./Mr./Mrs./Ms. (Family Name) (First Name) (MI) Accompanying Person(s) ______(Family Name) (First Name) (MI)

______(Family Name) (First Name) (MI)

Registrant Mailing Address Institution/Clinic/Home ______Please check one Institution □ Street ______□ Private Clinic City ______State ____ Country ______Zip/Postal Code ______□ Home Tel. No. ( ) ______FAX No. ( ) ______

E-MAIL: ______Specialty: ______

REGISTRATION FEES: Registration is personal and non-transferable. Your fee must accompany this registration form. BEFORE FEBRUARY 15, 2008 AFTER FEBRUARY 15, 2008

□ ICA Fellows, Associate Fellows† (USD) $400 (Entire Congress) (USD) $500 (Entire Congress)

□ ICA Fellows, Associate Fellows† (Daily Fee) (USD) $125 per day (USD) $175 per day

PLEASE INDICATE DAYS ATTENDING: □ Sunday □Monday □Tuesday

□ All Other Non-Fellows (USD) $600 (Entire Congress) (USD) $700 (Entire Congress)

□ All Other Non-Fellows (Daily Fee) (USD) $175 per day (USD) $225 per day

PLEASE INDICATE DAYS ATTENDING: □ Sunday □Monday □Tuesday

□ Host Country Physicians–Japan (USD) $100 (Entire Congress) (USD) $125 (Entire Congress) including China, Korea and India

PLEASE INDICATE DAYS ATTENDING: □ Sunday □Monday □Tuesday □ Residents, Interns & Students, No Charge No Charge RN’s/PA’s/Allied Medical Services* *(Requires a letter from the hospital verifying position) †Associate Fellows of the ICA, in good standing, ARE NOT REQUIRED TO PAY A REGISTRATION FEE as part of their membership benefit. □ PLEASE FORWARD INFORMATION AND AN APPLICATION FOR FELLOWSHIP REGISTRATION PAYMENT INFORMATION Must be in U.S. funds, drawn on a U.S. bank. Credit Card Type: □ □ □ □ Check Amount: (USD) $______Check Nr. ______Credit Card Number: Expiration Date: ______/______

Name As It Appears on Card:

Authorized Signature:

REGISTRATION CANCELLATION POLICY: A written request must be received no later than February 15, 2008, less a $50 administrative fee. There will be a 50% processing fee for all cancellations received after February 15, 2008 and before March 1, 2008. Fees are non-refundable after March 1, 2008.