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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.