Register Now! Philadelphia Spine Summit: Inaugural Meeting On the campuses of Thomas Jefferson University and University of Pennsylvania May 8-9, 2015 _____________________________________________________________________ Male  Female Last Name First Name MI ____________________________________________________________________________ Title (Dr, Mr, Ms.) Personal Title (II, Jr) Degree Specialty _______________________________________________________________________________ Affiliation/Organization Mailing Address _______________________________________________________________________________ City State Zip _______________________________________________________________________________ Telephone  Work  Home  Cell Fax Email ___ ____ ____ _____ Web ID (Please provide the last four digits of your Social Security Number as your Web ID. This will allow you to access your CME transcript at anytime after the course.) Optional Dinner - Friday, May 8, 2015: Would you be interested in attending a group dinner on Friday, May 8, 2015 after the conference? Please respond: □Yes □No (If there is enough interest, dinner will be confirmed and additional details will be available on the course website) Please do not include me in upcoming events mailing lists. Are you a Jefferson Alum? If yes, what year? ____________________ *How did you hear about this event? ____________________________________________________ REGISTRATION FEES Didactic Presentations Friday, May 8, 2015 $250 Cadaver Laboratory Saturday, May 9, 2015 $500 Both Days $650 To register please use one of the following options: Register Online: http://jeffline.jefferson.edu/jeffcme/SpineSummit/ Fax: You may fax this form with credit card payment to (215) 923-3212 Phone: For further information, please call the Office of CME at 1-888-JEFF-CME or 215-955-6992 Mail: Philadelphia Spine Summit - Office of CME; 1020 Locust Street, Suite M-5; Philadelphia, PA 19107 Payment: Please make check payable to Sidney Kimmel Medical College, Office of CME, or provide Credit Card Information. Do not send cash. Registration will not be processed unless full payment is received. □ Check is enclosed. Check Number: ___________ I hereby authorize use of my: □ Amount $ _____________ □ Visa Mastercard Amount $ _____________ Account Number: ______________________________________ Exp Date: ___________________ Billing Address (if different from above): ________________________________________________ If you have any special needs, please contact the CME Office by April 24, 2015 at 1-888-JEFF-CME or 215-955-6992.