Please print or type all information. Duplicate form for multiple registrations.
To expedite registration, fax this form with your credit card noted: 1-602-301-8323.

Have you ever registered for a previous Mayo Clinic Scottsdale Anesthesiology course?
___ Yes ___ No

Your type of practice:	Years in practice:
___ Solo	___ 0-4
___ Group	___ 5-10
___ University	___ 11-15
___ Resident/Fellow	___ 16-25
___ Retired	___ > 25
___ Other: ________________________________________________

Name/Degree_________________________________________________

Specialty____________________________________________________

Address ____________________________________________________

City / State / Zip______________________________________________

Daytime Telephone (___)________________ Fax (___)________________

Registration Fee ($480 physicians/$340 CRNAs)
Mexican Fiesta
(Adults - $20  Children under 12 - $10)
#_____Adults _____Children
How many will attend the Welcome Reception?
(2 Complimentary) #_____Adults _____Children
Total Payment Enclosed $__________(Please indicate form of payment below.)

Please make checks payable to Mayo Clinic Scottsdale
___ Check enclosed ___ Visa ___ MasterCard ___ Discover

Card Number ________________________________________________

Expiration date (mo/yr) __________________________________________

Signature _____________________________ Date ___________________

FOR OFFICE USE ONLY: 99-401D
Rec'd _______ Reg'd _______ Auth # _______CK # _______
Continuing Medical Education - Mayo Clinic Scottsdale
13400 East Shea Boulevard - Scottsdale, Arizona 85259

Return to: Ninth Annual "Current Topics in Anesthesiology"

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