MEI: Temporal Bone Dissection Course Registration Form

Michigan Ear Institute
Temporal Bone Surgical Dissection Courses
Registration Form

5-Day Courses		Fees
October 2-6, 2006 November 6-10, 2006 March 5-9, 2007 October 1-5, 2007 November 5-9, 2007 March 3-7, 2008 October 6-10, 2008	November 3-7, 2008 March 2-6, 2009 October 5-9, 2009 November 2-6, 2009 March 1-5, 2010 October 4-8, 2010 November 1-5, 2010	Physicians: $1500.00 Residents: $1100.00 Course fees are subject to change.

Type of Practice Private Practice Hospital-Based Practice Physician in Training: Year _____	Drill Preference Right-handed Left-handed	How did you hear about the course? Advertisement Brochure Colleague Internet Other (Please Specify) _________________________
Organization Name ___________________________
E-mail Address ___________________________

Payment Method

Visa Mastercard Check Enclosed

Account Number_____________________ Exp. Date _______

Signature ____________________________________________________

Checks: Please make checks payable to Michigan Ear Institute and return with registration form to:

Michigan Ear Institute
Attention: Alison Devine
30055 Northwestern Hwy. #101
Farmington Hills, MI 48334

Note: Lodging is available at area hotels. A list of hotels will be sent with your registration confirmation.