<p> REGISTER ONLINE at www.ccf.org/florida/cme</p><p>Please enter your name as you wish it to appear on your badge.</p><p>Prefix: DR MR MRS MISS Other______Suffix: DO MD PhD RN Other______</p><p>Last name: ______First name: ______</p><p>Address: ______</p><p>City: ______State/Province: ______</p><p>Zip/Postal Code: ______Country: ______</p><p>Phone: ______Fax: ______</p><p>E-mail: ______Specialty: ______</p><p>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</p><p>20th Anniversary International Colorectal Disease Symposium, February 12-14, 2009</p><p>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</p><p>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.</p><p>Additional Programs Endorectal Ultrasonography Course, February 11, 2009</p><p>Registration fee includes breakfast, lunch breaks, syllabus book complimentary transportation $425 $425 $425 $425</p><p>TEM - Transanal Endoscopic Microsurgery Hands-on Workshop, February 15, 2009</p><p>Registration fee includes breakfast, lunch, breaks, syllabus book $375 $375 $375 $375</p><p>4th International Congress of Laparoscopic Colorectal Surgery, February 10-11, 2009 Please visit the ISLCRS website for additional information: www.islcrs.org</p><p>Late / On-site Fee </p><p>This fee will be added to all registrations received after February 5, 2009 $75 $75 $75 $75</p><p>Total amount enclosed or to be charged $ ______</p><p>PAYMENT METHODS</p><p>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: ______</p><p>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.</p><p>OFFICE USE sympf09w28 Rec’d______Reg ID______Date entrd______Registrar______</p>