<p> 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]</p><p>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</p><p>(Please Print) MD/MBBS/RN, RVT, PA (Family Name) (First Name) (MI) Registrant</p><p>Dr./Prof./Mr./Mrs./Ms. (Family Name) (First Name) (MI) Accompanying Person(s) ______(Family Name) (First Name) (MI)</p><p>______(Family Name) (First Name) (MI)</p><p>Registrant Mailing Address Institution/Clinic/Home ______Please check one Institution □ Street ______□ Private Clinic City ______State ____ Country ______Zip/Postal Code ______□ Home Tel. No. ( ) ______FAX No. ( ) ______</p><p>E-MAIL: ______Specialty: ______</p><p>REGISTRATION FEES: Registration is personal and non-transferable. Your fee must accompany this registration form. BEFORE FEBRUARY 15, 2008 AFTER FEBRUARY 15, 2008</p><p>□ ICA Fellows, Associate Fellows† (USD) $400 (Entire Congress) (USD) $500 (Entire Congress)</p><p>□ ICA Fellows, Associate Fellows† (Daily Fee) (USD) $125 per day (USD) $175 per day</p><p>PLEASE INDICATE DAYS ATTENDING: □ Sunday □Monday □Tuesday</p><p>□ All Other Non-Fellows (USD) $600 (Entire Congress) (USD) $700 (Entire Congress)</p><p>□ All Other Non-Fellows (Daily Fee) (USD) $175 per day (USD) $225 per day</p><p>PLEASE INDICATE DAYS ATTENDING: □ Sunday □Monday □Tuesday </p><p>□ Host Country Physicians–Japan (USD) $100 (Entire Congress) (USD) $125 (Entire Congress) including China, Korea and India</p><p>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: ______/______</p><p>Name As It Appears on Card:</p><p>Authorized Signature: </p><p>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. </p>