One-Day Lecture and Live Surgical Course  

Saturday, April 28, 2001  

Dr. Michael Keenan
3720 California Avenue, SW, Seattle, WA  98116…tel: 206-938-1113

Registration:

Please complete the following registration form and fax to Jennifer Chase of Innova LifeSciences Corporation

Fax: 925-287-1916              Tel: 925-934-6768

 Name__________________________________________________________________ 

Specialty_______________________________________________________________ 

Address________________________________________________________________ 

City___________________________________________________________________

State______________________________ Zip__________________________________ 

Telephone #________________________Fax #________________________________ 

E-mail_________________________________________________________________

Method of Payment                  ÿ  Check             ÿ  Credit Card 

Total Amount             *$649.00; please make checks payable to Dr. Michael Keenan 

Credit Card                               ÿ  Visa                ÿ  Mastercard 

Card Number:   _________________________________Exp. Date________________ 

Name as it appears on card:   ______________________________________________ 

Signature:_______________________________________________________________

*As a special incentive, Innova Corporation will deduct the course price from any purchases made at the course!

Accreditation:  All participants will be awarded 4 FAGD/MAGD credit hours, upon completion of the course.