Meeting Registration Form

You may register online using a credit card or complete the form below and mail your payment to: AMA, Division of CME, 515 North State Street, Chicago, IL 60610 or fax to (312) 464-5830. Please make your check payable to the American Medical Association.

Please print or type

Last Name ______________________ First Name _____________________ Middle Initial ______

Medical Education Number _________________________________________________________________

Mailing Address _________________________________________________________________________

City _______________________ State ______________ Zip ________

E-mail Address ________________________________________________________________________

Daytime Phone Number ________________ Fax Number ____________

Pre-session Questionnaire

1. Have you ever accessed the Web?

___ YES ___ NO

2. Are you comfortable surfing the Web without assistance?

___ YES ___ NO

If you are not comfortable accessing the Web, we recommend that you attend the Pre-session Internet (hands-on) Tutorial.

___ Please check if you want to signup for the Pre-session Internet Tutorial

For Credit Card Payment:

___ Visa ___ MasterCard ___ American Express ___ Optima

Card # _______________________________________

Exp. Date ____________ Name as it appears on card: ________________

Signature ______________________________ Date _________