Connecticut Orthopedic Society

CONNECTICUT ORTHOPEDIC SOCIETY MEETING REGISTRATION FORM

Programs & Seminars | Annual Meeting | Apply for Membership | Membership Dues

You can fill out this SECURE Online form or you can print, fill out and mail with your check or credit card information to:

Connecticut Orthopedic Society
Susan Schaffman - Executive Director
26 Riggs Avenue
West Hartford, CT 06107
Phone: (860)561-5205
FAX (860)561-5514
Email: sasshops@aol.com

MEETING REGISTRATION FORM

I (we) will attend the program

Attendee Name

Second Attendee Name

Practice

Practice Manager’s

Address

City

State Zip

Telephone

Fax

E-mail
(For registration confirmation purposes)

Credit Card Information

Type of Card

MC or Visa

Name on Card

Account No.

Expiration Date

May 16, 2008 - Annual Meeting - Amount billed to your account will be $100.00