ECTSS 53rd Annual Meeting Brochure

54 TH A NNUAL M EETING 2016 Loews Don CeSar Hotel, St. Pete Beach, Florida October 19 - 22, 2016

R EGISTRATION F ORM ( F ORM MUST BE RECEIVED BY O CTOBER 3, 2016)

Name (please print)

Designation/Degree

Affiliation Name

Address

City / State / Zip

Phone / Fax

E - mail

R EGISTRATION F EES

� Member Includes Welcome Reception, Continuing Medical Education Programs, Breakfast, Refreshment Breaks, Exhibits, Movie Night, Case Bowl, Magovern Lectureship Luncheon, Scientific Poster Rounds and President’s Reception Please note that your 2016 - 2017 membership dues must be paid in full to qualify for the member rate. Unpaid members registration forms will not be processed without dues payment.

$ 150 =

$ _________

$ 225 =

$ _________

� Membership Dues

� Non-Member Includes Welcome Reception, Continuing Medical Education Programs, Breakfast, Refreshment Breaks, Exhibits, Movie Night, Case Bowl, Magovern Lectureship Luncheon, Scientific Poster Rounds and President’s Reception � Resident / Fellow / Student Includes Welcome Reception, Continuing Medical Education Programs, Breakfast, Refreshment Breaks, Exhibits, Magovern Lectureship Luncheon and Scientific Poster Rounds � Non-Physicians Includes Welcome Reception, Continuing Medical Education Programs, Breakfast, Refreshment Breaks, Exhibits, Movie Night, Case Bowl, Magovern Lectureship Luncheon, Scientific Poster Rounds and President’s Reception � Spouse / Guest Includes Welcome Reception, Magovern Lectureship Luncheon and President’s Reception Please note that meeting participants are responsible for their own housing and travel reservations. For discounted hotel reservations, contact the Loews Don CeSar Hotel at 800-282-1116, request the reservation department and inform the agent that you are with the Eastern Cardiothoracic Surgical Society.

$ 375 =

$ _________

No charge $ _________

$ 150 =

$ _________

$ 100 = $ _________

SUB TOTAL $ _________