Connecticut Ear, Nose and Throat Society Annual Meeting

Connecticut Ear, Nose and Throat Society
Annual Meeting
Thursday April 9, 2015
The Aqua Turf Club, 556 Mulberry Street, Plantsville, Connecticut
Physician Registration Form
NAME:_________________________________________________________________
(please print)
ADDRESS:______________________________________________________________
(please print)
CITY:_____________________________________STATE:______ ZIP:_____________
TELEPHONE:___________________________________________________________
EMAIL ADDRESS:________________________________________________________
______ Yes, I am planning on attending the November 14, 2014 Annual Education Program
______ No, I am unable to attend the November 14, 2014 Annual Education Program
Member Physician Fee:
$100.00
Non-Member Fee:
$200.00
Non-M.D,/Office Personnel:
$ 75.00
Residents:
Complimentary
(please make checks payable to CT ENT Society)
Please mail this form with your payment to:
CT ENT Society, P.O. Box 863, Litchfield, CT 06759
Fax: 860-567-3591
This activity has been planned and implemented in accordance with the Essentials and Standards of the Connecticut State Medical Society
through the joint sponsorship of CSEP and The Connecticut ENT Society. CSEP is accredited by the CSMS
to provide continuing medical education for physicians.
CSEP designates this educational activity for a maximum of 6.0 credit hours in category I credit toward the AMA Physicians Recognition Award.
Each physician should claim only those hours of credit that he/she spent in the activity.
(This form may be copied for additional registrations)
************************************************************************
(for CT ENT office use)
Check # ___________
Received __________
Amount __________
DEADLINE FOR REGISTRATION IS March 30, 2015
Contact Debbie Osborn at debbieosborn36@yahoo.com or cell 860-459-4377