November 20-21, 1998
Hong Kong

I would like to register for  Controversies in Cardiothoracic Surgery (Please type)

Personal Details
 
  Title: Prof. / Dr. / Mr. / Ms. 
 
  First name: ______________________________    Last name: ________________________________
 
  Mailing address: ____________________________________________________________________
 
  _________________________________________________________________________________
 
  Telephone: __________________________________  Fax: __________________________________
 
  E-mail (if available): ____________________________  Specialty: _____________________________
 
Registration
 
    __  Physicians (USD450/HKD3510)
    __  Nurses/Paramedics (USD75/HKD585)
 
 
    __  Physicians* (USD300/HKD2340)
    __  Congress Banquet (USD75/HKD585)
 
 
    __  Residents/Fellows** (USD150/HKD1170)
 
 
    * MITSIG / ELSA Members / "SURVIVAL" Group (Please specify) 
    ** letter from Chairman of Department required
 
 

Payment Methods
 
    __  *Money order / Bank cheque (enclosed)
 
    __  Credit card (Master / Visa)  HKD______________________ 
 
    Card no.:________________________________  Expire on:____________________________ 
 
    Card holder name: _________________________  Signature: ____________________________
 

Print out this form or download the PDF file.  Mail or fax the completed form to:
.
Controversies in Cardiothoracic Surgery
c/o Division of Cardiothoracic Surgery
Department of Surgery
Prince of Wales Hospital
Shatin, N.T.
Hong Kong
 
Telephone: (852) 2632 2629 
Fax: (852) 2637 7974 
E-mail: yimap@cuhk.edu.hk 
 
* Crossed Cheques should be made payable to "The Chinese University of Hong Kong"