CUA BPH Hands-on-Training (HOT) Course TWO SESSIONS AVAILABLE: Sunday, June 28th from 16:45 - 18:30 (12 spots available) DATES Monday, June 29th from 7:00 - 8:45 with breakfast (12 spots available) Please indicate date of attendance: Identification Name: Address: City: Province: Postal Code: Tel.: Fax: Email: Credit Card Payment A $25 reservation fee is required upfront I _______________________________ , authorize the Canadian Urological Association to charge my credit card. For services rendered. Not to exceed the amount shown. AMOUNT: ____________________($ CAD) CREDIT CARD TYPE: _____________________________ EXPIRATION DATE: ___________________ CREDIT CARD NUMBER: _______________________________________________________________________ NAME (as it appears on card): __________________________________________________________________ SIGNATURE: ________________________________________ If you have any questions, please contact: Raffaella Leroux [email protected] T: 514-395-0376 ext. 41 | F: 514-395-1664 www.cua.org DATE: _____________________________ This course has been developed and accredited by the CUA with logistical support from