Registration
Cardiovascular & Thoracic Surgery Core Curriculum Review - 2008

Name: _______________________________________________________________________

Address: _____________________________________________________________________

City: ____________________________________________ State:_______ Zip: _____________

Phone: _____________________ E-mail address: _____________________________________

Discover _______   American Express ________   Visa/Mastercard ________

Name as it appears on credit card __________________________________________________

Card# __________________________________________________ Exp. Date ____________

Signature _____________________________________________________________________

Special dietary requirements:
Vegetarian _____ Other _________________________________________________________

Please make checks payable to Intermountain Healthcare CME, and mail to:

Continuing Medical Education
36 South State Street, Suite 1600
Salt Lake City, UT 84111

or

Fax this completed form with credit card information to (801) 442-3929.

NOTE: Payment is due at time of registration.
If your address changes after registration, please notify the CME office.