NON-PROFIT ORGU.S. POSTAGE

PAIDTAMPA, FL

PERMIT NO. 1632

University of South Florida Office of Continuing Professional Development, MDC #60, 12901 Bruce B. Downs Blvd.Tampa, FL 33612-4799

TO ATTEND THIS CME ACTIVITY AND RECEIVE SCHOLARSHIP FUNDS, YOU MUST HAVE THE ORTHOPAEDICRESIDENCY/FELLOWSHIP PROGRAM DIRECTOR SIGN THIS CME REGISTRATION FORM. AS DIRECTOR OF THE ORTHOPAEDIC RESIDENCY/FELLOWSHIP PROGRAM, IT IS ACCEPTABLE FOR THE RESIDENT/FELLOW LISTED ON THIS COURSE REGISTRATION FORM TO ATTEND THIS CME ACTIVITY.

PRINT PROGRAM DIRECTOR’S NAME: SIGNATURE OF PROGRAM DIRECTOR: DATE

INSTITUTION/HOSPITAL NAME:

NAME

ACADEMIC DEGREE

ADDRESS

CITY STATE POSTAL CODE

DAYTIME PHONE CELL PHONE FAX

EMAIL ADDRESS

GENDER:

MALE

FEMALE

RESIDENT/FELLOW REGISTRATION FORM

MD DO RESIDENT FELLOW TYPE OF CREDIT REQUESTED:

PLEASE CHECK ALL THAT APPLY:

YES, I WILL ATTEND, NO ROOM NEEDED YES, I WILL ATTEND, WILL NEED A ROOM

ROOMING INFORMATION

THURSDAY, SEPTEMBER 11 FRIDAY, SEPTEMBER 12 NON SMOKING SMOKING KING 2-DOUBLES

CREDIT CARD: VISA MASTERCARD AMEX

IN THE AMOUNT OF $

CARD NUMBER

EXP. DATE SECURITY CODE/CCV

NAME ON CARD (PRINT)

SIGNATURE

PN2009899/1137

(AMEX-4 digits on front, MC/Visa-3 digits on back)

Resident/Fellow Scholarship Policy and Procedure Form9TH ANNUAL BOSTON ORTHOPAEDIC TRAUMA SYMPOSIUMSEPTEMBER 12-13, 2008BOSTON, MASSACHUSETTS

Scholarship Funds will provide for:• A tuition waiver and attendance at the specified CME activity listed above.• One roundtrip coach airline or train ticket from your office/work to the course destination, or mileage reimbursement for a distance of 300 miles or more

(up to a maximum of $500 for transportation).Taxi, rental car and other ground transportation are not included in the scholarship.• Two nights at the course location/hotel, room and tax only.• Meals, receptions and refreshment breaks associated with the CME course.

You are responsible for providing and payment of:• All ground transportation including taxi, rental car, tolls and parking fees.• Meals/food not provided as part of the CME course.• Phone, fax, internet, in-room dining, movies, recreational, and personal and miscellaneous hotel amenities.• Scholarship funds cannot be used to pay for any expenditures in connection with a spouse/guest attending any portion of this activity.

Steps to Follow:• Complete the Resident/Fellow Scholarship Form. Be sure to have your Residency/Fellowship Program Director sign the form.• Fax or mail the form as directed.You will be required to provide credit card information – if you register and do not attend, the cost of your hotel room ($259

plus all applicable taxes) will be billed to your credit card.• A travel and expense form and W9 will be provided at the program for reimbursement purposes.• Your signature on this form signifies acceptance of these terms. No Exceptions.

If cancellation becomes necessary, please contact USF OCPD directly as soon as possible, so that residents who become wait-listed can register for the course.

Register By Fax: (813) 974-3217Questions and Information: (813) 974-4296

Return Registration Form To:University of South FloridaHealth Professions Conferencing Corporation (HPCC)PO Box 864240Orlando, FL 32886

NAME

ACADEMIC DEGREE

ADDRESS

CITY STATE POSTAL CODE

DAYTIME PHONE CELL PHONE FAX

EMAIL ADDRESS

GENDER:

MALE

FEMALE

REGISTRATION FORM

REGISTER ONLINE AT WWW.CME.HSC.USF.EDU/BOSTONTRAUMAREGISTER BY FAX: (813) 974-3217 RETURN REGISTRATION FORM AND PAYMENT TO:UNIVERSITY OF SOUTH FLORIDAHEALTH PROFESSIONS CONFERENCING CORPORATION (HPCC)PO BOX 864240ORLANDO, FL 32886-4240

A CONFIRMATION LETTER WILL BE SENT UPON RECEIPT OF YOUR REGISTRATION AND PAYMENT (NO REGISTRATION IS CONFIRMED WITHOUT FULL PAYMENT)

PHYSICIAN RESIDENT FELLOW

NURSE PA OTHER

TYPE OF CREDIT REQUESTED:

LICENSE # REQUIRED FOR NURSES

TUITIONCOURSE FEESSURGEONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$200.00RESIDENTS AND FELLOWS . . . . . . . . . . . . . . . . . . . .$50.00 BOSTON UNIV. MED. CENTER SURGEONS OR STAFF . . . . . . . . . . . . . . . . . . . . . . . .$35.00

IF YOU ARE A RESIDENT/FELLOW APPLYING FOR ASCHOLARSHIP, PLEASE USE THE RESIDENT/FELLOWSCHOLARSHIP REGISTRATION FORM.

CREDIT CARD: VISA MASTERCARD AMEX

IN THE AMOUNT OF $

CARD NUMBER

EXP. DATE SECURITY CODE/CCV

NAME ON CARD (PRINT)

SIGNATURE

PN2009899/1137

(AMEX-4 digits on front, MC/Visa-3 digits on back)

ENCLOSED IS MY CHECK MADE PAYABLE TO: USF HPCC IN THE AMOUNT OF $____________________________________________.

MAIL TO ADDRESS LISTED ABOVE.