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REGISTER ONLINE at www.ccf.org/florida/cme

Please enter your name as you wish it to appear on your badge.

Prefix: DR MR MRS MISS Other______Suffix: DO MD PhD RN Other______

Last name: ______First name: ______

Address: ______

City: ______State/Province: ______

Zip/Postal Code: ______Country: ______

Phone: ______Fax: ______

E-mail: ______Specialty: ______

Alumnus Residents/Fellows Nurses and (Letter of verification from Physicians (Trained at Cleveland Clinic Allied Health Registration Fees Program Director must for at least three (3) months) accompany registration) Professionals

20th Anniversary International Colorectal Disease Symposium, February 12-14, 2009

Registration fee includes breakfast, lunch and 2 $675 by 11/30/08 $475 by 11/30/08 $575 by 11/30/08 $375 by 11/30/08 breaks per day, cocktail reception, syllabus on CD, conference bag and 20th anniversary gifts $725 after 11/30/08 $525 after 11/30/08 $625 after 11/30/08 $425 after 11/30/08

Syllabus book Note: a CD syllabus is included with the registration fee. If you would like a written $50 $50 $50 $50 copy, please order here.

Additional Programs Endorectal Ultrasonography Course, February 11, 2009

Registration fee includes breakfast, lunch breaks, syllabus book complimentary transportation $425 $425 $425 $425

TEM - Transanal Endoscopic Microsurgery Hands-on Workshop, February 15, 2009

Registration fee includes breakfast, lunch, breaks, syllabus book $375 $375 $375 $375

4th International Congress of Laparoscopic Colorectal Surgery, February 10-11, 2009 Please visit the ISLCRS website for additional information: www.islcrs.org

Late / On-site Fee

This fee will be added to all registrations received after February 5, 2009 $75 $75 $75 $75

Total amount enclosed or to be charged $ ______

PAYMENT METHODS

CREDIT CARD To expedite your registration, please register online (www.ccf.org/florida/cme) or fax this completed form to (954) 659-5491. Visa Mastercard American Express Card Number: ______Security code (required): ______Exp. Date: ______

CHECK Make check payable to “Cleveland Clinic Florida”. Reference “sympf08W28” on check. Checks must be in US Dollars and drawn on a US bank. Mail check and registration to Cleveland Clinic Florida, Attn: Continuing Medical Education, PO Box 277545, Atlanta, GA 30384-7545.

OFFICE USE sympf09w28 Rec’d______Reg ID______Date entrd______Registrar______