10 / 11
R
EGISTRATION
F
EES
�
Member
Includes Welcome Reception, Continuing Medical Education Programs, Breakfast,
Refreshment Breaks, Exhibits, Movie Night, Case Bowl, Magovern Lectureship
Luncheon, Scientific Poster Rounds and President’s Reception
Please note that your 2016
-
2017 membership dues must be paid in full to
qualify for the member rate. Unpaid members registration forms will not be
processed without dues payment.
$ 150 =
$ _________
�
Membership Dues
$ 225 =
$ _________
�
Non-Member
Includes Welcome Reception, Continuing Medical Education Programs, Breakfast,
Refreshment Breaks, Exhibits, Movie Night, Case Bowl, Magovern Lectureship
Luncheon, Scientific Poster Rounds and President’s Reception
$ 375 =
$ _________
�
Resident / Fellow / Student
Includes Welcome Reception, Continuing Medical Education Programs, Breakfast,
Refreshment Breaks, Exhibits, Magovern Lectureship Luncheon and Scientific Poster
Rounds
No charge $ _________
�
Non-Physicians
Includes Welcome Reception, Continuing Medical Education Programs, Breakfast,
Refreshment Breaks, Exhibits, Movie Night, Case Bowl, Magovern Lectureship
Luncheon, Scientific Poster Rounds and President’s Reception
$ 150 =
$ _________
�
Spouse / Guest
Includes Welcome Reception, Magovern Lectureship Luncheon and President’s
Reception
$ 100 = $ _________
SUB TOTAL $ _________
Please note that meeting participants are responsible for their own housing and
travel reservations. For discounted hotel reservations, contact the Loews Don
CeSar Hotel at 800-282-1116, request the reservation department and inform the
agent that you are with the Eastern Cardiothoracic Surgical Society.
Name (please print)
Designation/Degree
Affiliation Name
Address
City / State / Zip
Phone / Fax
E
-
54
TH
A
NNUAL
M
EETING
2016
Loews Don CeSar Hotel, St. Pete Beach, Florida
October 19 - 22, 2016
R
EGISTRATION
F
ORM
(
F
ORM MUST BE RECEIVED BY
O
CTOBER
3, 2016)