Registration Form First Annual QMP Reconstructive Surgery Symposium September 28-30, 2007 Name: __________________________________________________________ Address: ________________________________________________________ City: ________________________________ State: ______ Zip: __________ E-mail: ____________________________ Country______________________ Telephone: __________________________ Fax: _______________________ REGISTRATION FEES & DEADLINE       BEFORE 9/10/07     AFTER 9/10/07      Physician     $1000     $1200      Resident     $650     $750 MAKE CHECKS PAYABLE TO: Quality Medical Publishing, Inc. Send your registration form to: Quality Medical Publishing, Inc. 2248 Welsch Industrial Ct. St. Louis, MO 63146 USA Attn: Andrew Berger OR Fax your registration and credit card information to: (314) 878-9937 CANCELLATION POLICY: Registration is 50% refundable only if a written cancelation is received at QMP before September 1, 2007. No refunds will be given after September 1, 2007 for any reason. Payment (check one): Credit Card:   Discover   Visa   Mastercard   American Express Check Enclosed Card #: ____________________________ Exp. Date: ______ Verification #: _____ Print Card Holder's Name: _____________________________________ Signature: ____________________________________________________