ASIPP : : : Association Of Interventional Pain Physicians

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" The Voice Of Interventional Pain Management "

Registration Form
Spinal Cord Stimulation & Cadaver Workshop
Comprehensive Review Course & Interventional Cadaver Workshop
November 30 - December 2, 2007
Fees include all sessions, all handout materials, continental breakfast Saturday and Sunday, and lunch on Saturday

IMPORTANT: (Please answer all the questions that apply)

Please print exactly as you wish your name to appear

Primary Specialty Certificates:
	Anesthesiology
	Neurosurgery
	Neurology
	PMR or Neurology
	Physiatry
	Radiology
	Orthopaedic Surgery
	Psychiatry

Pain Medicine Subspecialty Certification:
	American Board of Anesthesiology
	American Board of Pain Medicine
	American Board of Interventional Pain Physicians
	Fellow of Interventional Pain Practice (FIPP)

Specialty Designation:
	09 - Interventional Pain Management
	72 - Pain Management
	Other:

Percentage of Interventional Pain Management Practice:

0% 1-25% 26-50% 51-75% > 75%

Years in Interventional Pain Management Practice:

0 1-5 6-10 > 10

REGISTRATION INFORMATION
Approximately 70 participants will be allowed in the Workshop. Please complete the enclosed registration form and return to ASIPP with payment (your application will not be processed if payment does not accompany registration form). ASIPP reserves the right to cancel this Workshop and/or Review Preparation Course upon reason-able notice and will assume no financial obligation to registrants for cancellation of the course for reasons beyond its control. Registration fees will be refunded. However, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. Registrants who are not accepted into this workshop will receive notice by mail with their returned check.

CANCELLATION POLICY
ASIPP requires a 30-day notice for registrant’s cancellation. Cancellations must be submitted in writing and received by
October 31, 2007. An administrative fee of $200.00 will be assessed. Cancellations after October 31, 2007, but prior to November 15, 2007, will forfeit 50% of their registration fee. No cancellations accepted after November 15, 2007. Refunds will be sent after the conclusion of the meeting.

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.

Comprehensive Spinal Cord Stimulation
Review Course and Hands-on Cadaver Workshop

	On or before Oct. 31, 2007	After Oct. 31, 2007
Member	$2,200	$2,500
Non-Member	$2,500	$2,700

PAYMENT INFORMATION

MasterCard Visa AmEx Discover

(Credit Card Number)

(Name on Card)

(Expiration Date)

(Security Code)

ACCOMODATIONS: I will be staying at...

The Peabody Memphis

Inform agent that you are booking for American Society of Interventional Pain Physicians. We have secured a group room rate of $179. Reserve rooms early—all unbooked rooms will be released November 6, 2007.

Location
The Peabody Memphis—Memphis, TN
149 Union Avenue / Memphis, TN 30103
Phone (901) 529-4000 / Toll Free 1-800-PEABODY
Fax (901) 529-3646