10th Physician-Legal Issues Conference

Registration

*Denotes required field. *Full Name: *First Name for Badge: (Badge will include "badge name," full name, company, city and state) Firm/Company/Agency: *Address: *City: *State: --- Select a State --- Non-U.S.A AL - Alabama AK - Alaska AS - American Samoa AZ - Arizona AR - Arkansas AA - Armed Forces - Americas AE - Armed Forces - Europe AP - Armed Forces - Pacific CA - California CO - Colorado CT - Connecticut DE - Delaware DC - District of Columbia FM - Federated States of Micronesia FL - Florida GA - Georgia GU - Guam HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MH - Marshall Islands MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota MP - Northern Mariana Isles OH - Ohio OK - Oklahoma OR - Oregon PW - Palau Islands PA - Pennsylvania PR - Puerto Rico RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VI - Virgin Islands VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming *Zip: *Phone: Fax: E-Mail: ABA ID (if known) States in which you are licensed:

PART A: REGISTRATION FEE         $295 General Attendee   $250 ABA Member (Non-Health Law Section member)   **$195 Health Law Section Member   $95 Academic/Judge/Government Lawyer   $50 ABA Law Student     $   Registration Total       ** Take advantage of this today when you sign up for the ABA Health Law Section membership! See Part B below!   PART B: HEALTH LAW SECTION MEMBERSHIP $50 Please sign me up for ABA Health Law Section membership! You must be a member of the American Bar Association to join the Health Law Section.   PART C: COURSE MATERIALS One set of course materials (either Paperback Book or CD ROM) is included in the registration fees. Please indicate your preference below. For an additional charge of $25, attendees can receive both versions of the materials. Please note that those registrants not indicating a preference will receive materials in the CD Rom version only. CD ROM Printed Book $25 - Both CD & Book     CHECKOUT PART A Registration Fee $ PART B Health Law Section Membership Registration Fee $ PART C Course Materials $   TOTAL FEES : $   METHOD OF PAYMENT VISA  MasterCard  American Express Card #: Exp. Date:   COMMENTS/DIETARY RESTRICTIONS