2011 Oregon Cardiovascular Symposium
Registration Form
June 4 - 5, 2011
Doubletree Lloyd Center Hotel
Portland, Oregon

Thank you for participating in the 2011 Oregon Cardiovascular Symposium. Please complete all fields of this registration form. If you are applying for CNE credit, it is important that we have your nursing license number. If you are applying for any form of CE credit, we must have a valid e-mail address. Immediately following the conference, your CE certificates will be provided electronically. Failure to provide an e-mail may prevent you from receiving your CE certificates in a timely manner. If you have any questions regarding the registration process, please contact Alan Morasch at 503-345-9294 or alan@cardiologyinoregon.org

* Last Name:

* First Name:

* Middle Initial:

* Designation (Title/Degree):

* Specialty:

* Institution/Practice:

* Address:

* City:

* State:

* Zip:

* Office Phone:

Office FAX:

* E-mail: (Note: A correct e-mail is required to get CME/CNE and other continuing education credits)

* Are you an ACC Member?

Yes

Your ACC Member Number:

Your Nursing License Number:

* Today's Date:

* Are you an OHSU Fellow?

Yes

Special Meal Request:

Vegetarian

Vegan

Other

* Are you planning on attending the Maintenance of Certification (MOC) course on Sunday morning?

Yes

No, I plan to attend the Symposium Sessions

Registration Fees

Thank you for registering in advance of the Symposium. Please check the appropriate registration fee. Following completion of the registration form you will be directed to a secure PayPal payment site where you can pay using your PayPal account or other credit card. In addition, you may opt of the credit card process and select the send a check for payment option:

Oregon Cardiovascular Symposium
PO Box 55424
Portland, OR 97238

Thank you again for participating in the 2011 Oregon Cardiovascular Symposium.

* Please check the appropriate box and payment amount. Registration fees will increase on May 20th.

$245 - Physician Regular Registration

$175 - Non-Physician Regular Registration

* Indicates Response Required

2011 Oregon Cardiovascular Symposium Registration Form June 4 - 5, 2011 Doubletree Lloyd Center Hotel Portland, Oregon

2011 Oregon Cardiovascular Symposium
Registration Form
June 4 - 5, 2011
Doubletree Lloyd Center Hotel
Portland, Oregon