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" The Voice Of Interventional Pain Management "

KSIPP
annual meeting | september 15-16, 2007 | lexington, kentucky
Registration
Fees include all sessions, all handout materials, Sunday continental breakfast, and two breaks

KSIPP ANNUAL MEETING REGISTRATION FEES

Please print exactly as you wish your name to appear

	Before Sept. 1	After Sept. 1
Active Member of KSIPP	$200	$250
Non-Member/Physician	$300	$350
MD in Fellowship Program	$ 50	$100
Associate Member of KSIPP	$150	$200
Non-Physician/Non-Member	$200	$250

KSIPP MEMBERSHIP DUES
	Active Member of KSIPP	$200	$250
	Non-Member/Physician	$300	$350

PAYMENT INFORMATION

MasterCard Visa AmEx Discover

(Credit Card Number)

(Name on Card)

(Expiration Date)

(Security Code)

Inform agent that you are booking for the American Society
of Interventional Pain Physicians. We have secured a group
room rate of $129.00. Reserve rooms early—special rate will
be honored until room block is filled.

First Name
Last Name
Degree:
Organization:
Address:
City:
State:
Zip Code:
*Phone:
*E-mail:
Fax:
	*VERY IMPORTANT: Please provide us with fax, phone and e-mail in the event we need to contact you. Registration is accepted on a first come, first serve basis. Organizers reserve the right to alter the schedule based upon the number of attendees.

CANCELLATION POLICY Cancellations must be submitted in writing and received by September 1, 2007; however, an administrative fee of $50 will be assessed. Cancellations after September 1, 2007, will forfeit 50% of their registration fee. No cancellations accepted after September 7, 2007. Refunds will be sent after the meeting. Organizers reserve the right to cancel the meeting and will assume no financial obligation to registrants for cancellation; but registration fees will be refunded. However, costs incurred by the registrant (i.e., airline fees, hotel fees, or penalties) are the responsibility of registrant.
Location Hyatt Regency Lexington 401 West High Street Lexington, KY USA 40507 1.859.253.1234 • fax 1.859.254.7430 http://lexington.hyatt.com