On-Line Conference Registration
Florida Academy of Pain Medicine Annual Meeting
Florida Society of Physical Medicine & Rehabilitation Spring Meeting
Florida Society of Interventional Pain Physicians Spring Meeting
June 11-13, 2004
Ritz-Carlton, Coconut Grove, Miami, FL

Please provide the following contact information:

Name
Address
City, State, Zip
Office Phone
FAX
E-mail
URL, if any

                                Conference Options
Please place checkmark and manually add the items you wish to attend and place the total in the appropriate field:

Workshop A 8-12 Update of Spinal Cord Stimulators. . . . . . . . . . . . . . . . . .$295.00           
Workshop B 8-12 Examination of the Neuromusculoskeletal. . . . . . . . . . . .$195.00           
Workshop C 1-5 RIT Regenerative Injection Therapy. . . . . . . . . . . . . . . . . . $500.00           
Workshop D 1-5 Cryoablation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $195.00           
Conf.Regis.Member FAPM, FSPMR,FSIPP By July 15. . . . . . . . . . . . . . . .$295.00           
Conf.Regis.Member FAPM, FSPMR,FSIPP After July 15. . . . . . . . . . . . . . $345.00           
NonMember By July 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $395.00           
NonMember After July 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $445.00           
Join FAPM when Registering By July 15 . . . . . . . . . . . . . . . . . . . . . . . . .  . . .$495.00           
Join FAPM when Registering After July 15 . . . . . . . . . . . . . . . . . . . . . . . . . . $545.00           
Resident/Fellow/Retired By July 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$  95.00           
Resident/Fellow/Retired After July 15 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$145.00           

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$

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Payment

Credit Card
(Visa &
Master Card Only)                                         

Visa Master Card          

Card Holder Name:  

        

Card Number:

   

CVV2: (3 digit number on reverse right side of card)

Please check over form and make sure all items are completed and correct; then click the submit button ONCE.