PUERTO RICO SOCIETY OF ANESTHESIOLOGISTS

PUERTO RICO SOCIETY OF ANESTHESIOLOGISTS

Selected Topics in Anesthesiology V July 3 - 6, 2008

PRE - REGISTRATION FORM

First Name: *

Middle Name:

Last Name 1: *

Last Name 2:

Address 1: *

Address 2:

City:

State:

Zip Code

Mobile Phone: *

Fax Number:

E Mail

ABA CERTIFICATION

Membership Status

Will stay at the Wyndham Rio Mar Resort during the Convention?

		Yes
		No

How many guests will participate in social activities?
One guest included in convention fee, additional guest at extra cost. *

Are you interested to enroll in the Sonogram Guided Regional Blocks and Vascular Access Workshop?
Additional cost $100.00
Limit 30 persons

		Yes
		No

Are you interested to enroll in the Echocardiography for Anesthesiology Workshop?
Additional cost $100.00
Limit 20 persons

		Yes
		No

I authorize the PRSA to include my personal information in the PRSA Directory? *

		Yes
		No

Comments:

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