__Yes, I (we) will attend the program on __________________________(fill in date).
__Enclosed is my (our) check for $______ (amount) per participant, to cover the program costs.
OR
__ Please charge the credit card for $_________(amount) per participant to cover the program costs.

Attendee Name______________________________________
Attendee Name______________________________________
Practice____________________________________________
Practice Manager’s __________________________________
Address____________________________________________
City_____________________________ Zip______________
Telephone__________________ Fax____________________
E-mail_________________________________
(Please provide for registration confirmation purposes)

Credit Card Information
Name on Card_______________________________________
Type of Card (circle one) Mastercard or Visa
Account No.________________________________________
Expiration Date_____________ Total Amount _____________
Signature___________________________________________

If you are paying by credit card, please mail or fax this form to:

Connecticut Orthopedic Society
Susan Schaffman, Executive Director
26 Riggs Avenue, West Hartford, CT 06107
FAX (860)561-5514
PHONE: (860)561-5202
Email: sasshops@aol.com