ECTSS 55th Annual Meeting Brochure

Name of Spouse/Guest: _____________________________________ Name(s) and age(s) of child(ren) attending: ___________________________________________ Nickname for name badge: _____________________________________ Shoe size: Men: �� S (7 - 8) �� M (8 - 10) �� L (10 - 12) Women: �� S (6 - 8) �� M (9 - 10) Only members indicating size will be able to pick up their meeting gift at registration. All others will receive a gift on an, as available basis, after all registered members have arrived.

� Please check here if you require vegetarian meals

� Please check here if you require gluten - free meals

Check the events you will attend: � � � Welcome Reception Movie Night Case Bowl Reception

�� Magovern Lectureship Luncheon �� Scientific Poster Rounds �� President’s Reception

� Resident/Fellow/Student President’s Reception

$ 160 = $ _________

� Exhibitor Banquet President’s Reception

$ 160 = $ _________

$ _________

TOTAL

PAYMENT:

� Enclosed is my check, made payable to “Eastern Cardiothoracic Surgical Society”, together with my registration form. Mail to: ECTSS Annual Meeting, Post Office Box 4, New York, NY 10024 - 0546.

� Please charge to:

American Express _____

MasterCard _____

Visa _____

Name on Card: _____________________________________________________

Billing Address: _____________________________________________________

Card #: _____________________________________________ Expiration Date: _______ / _______

Signature: ___________________________________________ CVS#: __________

� If paying by credit card, you may fax your registration to: (212) 721 - 1620 or register on - line at: www.ectss.org .

� Inquiries should be directed to: 646 - 797 - 5292 or meeting@ectss.org .

FOR OFFICE USE ONLY

Received: ____________________ Amount PD: ____________________ Payment Method: ____________________ Ck #: ____________________