Micromedical Technologies, Course Registration


	VNG / ENG
	VisualEyes
	VORTEQ/DVA

	Balance Platforms
	Balance Quest

	Rotational Chair
	System 2000
	System 2000 Reclining

	Video Goggles
	RealEyes xDVR
	RealEyes
	InView

	Caloric Irrigators
	Air Fx
	Aqua Stim

Assessment & Management of Balance Disorder Patients

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:
AAA Academy ID#:	Required for CEU credit


Registration Type
	Monday & Tuesday Course ($600 on or before 02/03/2012, $650 afterwards)

Payment Method
	Visa or Mastercard	Check

Course Information
Location: Scottsdale, AZ Dates: Monday, March 5 and Tuesday, March 6 Instructors: A. Tucker Gleason, Ph.D.; Jeff Walter, PT, DPT, NCS

Additional Information Question/Comment (Limit 8 lines): Note: DO NOT ADD YOUR CREDIT CARD INFORMATION. A Micromedical Representative will contact you by phone for that information.