Micromedical Technologies, Course Registration


	Balance Centers

	VNG / ENG
	VisualEyes
	VORTEQ/DVA

	Balance Platforms
	Balance Quest
	Balance Check

	Rotational Chair
	System 2000

	Video Goggles
	RealEyes
	InView

	Caloric Irrigators
	Cooling AirStar
	AirStar
	AquaStar

Assessment, Interpretation & Management of Balance Disorders

Note: Fields in RED must be entered to submit information. A representative of Micromedical Technologies will contact you within 2 business days to confirm and receive payment information. You can also print a copy prior to submission for your records. Alternatively you can print this form and mail your check payable to Micromedical Technologies to our corporate office:

ATTN Course Registration
Micromedical Technologies
10 Kemp Drive
Chatham, IL 62629

Personal Identification

Name* (First & Last):	Note: Accented and Tilde characters should be substituted with English characters (e.g. replace é with e)	Specialty:
Company Name*:	If not affliated with a particular company, please specify none.

Address Location	Business Address Home Address
Address*:

City*:		State*:
Zip*:		Country:
Daytime Phone: M-F 8am - 5pm CST*		Fax:

Email*:


Registration Type
	Thursday & Friday Course ($500 on or before 1/19/09, $550 after 1/19/09)
	Saturday Hands-on Seminar ($250 on or before 1/19/09, $300 after 1/19/09)

Payment Method
	Visa or Mastercard	Check

Course Information
Location: Tampa, FL Dates: Thursday, February 19, Friday, February 20, and Saturday, February 21, 2009 Instructors: Neil Shepard, Ph.D., Richard Clendaniel, P.T., Ph.D., Mark Haehn

Additional Information Question/Comment (Limit 30 lines): Note: DO NOT ADD YOUR CREDIT CARD INFORMATION. A Micromedical Representative will contact you by phone for that information.