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
˙ Check
˙
Credit Card
Total
Amount
*$649.00; please make checks payable to Dr. Michael Keenan
Credit
Card
˙
Visa
˙
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.