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Register for Cleveland Course, 6/18/09 - 6/20/09

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 5/18/09, $550 after 5/18/09)
Saturday Hands-on Seminar ($250 on or before 5/18/09, $300 after 5/18/09)
 
Payment Method
Visa or Mastercard Check
Course Information
Location: Cleveland, OH
Dates: Thursday, June 18, Friday, June 19, and Saturday, June 20, 2009
Instructors: Mohammed Hamid, M.D., Ph.D., Janet Riley, Aud., 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.