8/9/2019 IMANAHofstraRegistration

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IMANA-Hofstra Ethics Symposium, Hempstead, NY,

September 17-18, 2010

Registration FormNOTE: Print clearly using only a black or blue pen. Any field marked with an asterisk (*) is a required fieldYou may also register on-line at http://bit.ly/REGISTER-IHE. For more information on the conference, visithttp://ethics2010.imana.org. Call IMANA at (630) 932-0000 with any questions.

Name (as it appears in official identification) *: ___________________________________________________

Mailing Address*: __________________________________________________________________________

City*: _____________________ State/Province*: _________ Zip*: ________________

Country*: __________________ E-mail*: _____________________________________

Phone*: ____________________________________

Check the day or days you plan to attend in the row which best describes you, then calculate the net fees.

9/17 Price 9/18 Price

Speakers, Hofstra faculty and students, all medicalstudents Free

IMANA Life Member Physicians $50 $50

IMANA Member Physicians $75 $75

Other Physicians $100 $100

Non-Physicians $25 $25Physicians in training (Fellows and Residents),

Chaplains, other students $25

Total feesDiscount 20% if Sent Before

September 1, 2010 - ____

Net fees

8/9/2019 IMANAHofstraRegistration

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Payment

Total Amount Enclosed $______ Net fees must be paid in full.

Payment Method: CHECK (payable to IMANA)MC VISA AMEX DISCOVER

Name as it appears on the card. _____________________________________

Card Number: ___________________________________

Valid Thru: ___/____ (mm/yy)

Signature: _____________________________________

Billing Address (if different from Mailing Address)

_______________________________________________________________________

_______________________________________________________________________

CMEs

Credit Designation

The Islamic Medical Association of North America (IMANA) and the Dodge County Medical Society ofWisconsin designate this educational activity for a maximum of 13 AMA PRA Category I Credit(s).Physicians should only claim credit commensurate with the extent of their participation in the activity.Accreditation:

The Dodge County Medical Society of Wisconsin is accredited by the Wisconsin Medical Society (WMS) toprovide continuing medical education (CME) for physicians. The Islamic Medical Association of NorthAmerican and the Dodge County Medical Society take responsibility for the content, quality and scientificintegrity of this CME activity.

I want to receive the CMEs offered.

Form Submission

Mail enclosed registration form and check payable to IMANA, if applicable, to IMANA, 101 W. 22nd Street,Suite 106, Lombard, IL 60148 or fax the form to (630) 932-0005.