21st Annual Controversies, Problems and Techniques in Surgery Symposium: Thursday, December 9, 2004 through Saturday, December 11, 2003 at the Sheraton New York Hotel & Towers in New York City. Name                                                                                                                                                                                                                                                                            Degree Address                                                                                                                                     City/State                                                                                               Zip Code                      Daytime Phone (                        )                                                                                                Fax (                 )                                                                                                                       E-mail                                                                                                                                       Registration Fees: (Please check)      Practicing Physicians      $795           Resident and Fellows      $350 (Letter of verification from Chief of Service required) Reception: (Please Check) Madame Tussaud’s New York Wax Museum Friday, December 10, 2004, 6:30 – 8:00pm I will              will not          attend the reception. I will             will not           attend the reception. Luncheon          A guest will join me on Thursday, December 9, 2004         $65.00 Four Easy Ways to Register: *            Mail this form with your check, Visa, MasterCard or American Express number to: Center for Continuing Medical Education Albert Einstein College of Medicine 3301 Bainbridge Avenue Bronx, New York 10467 ¯              Fax this form with your Visa, MasterCard or American Express number to: 718-798-2336               Phone 1-800-575-4331 ext. 3665 with your Visa, MasterCard or American Express number Online www.surgerysymposium.org / www.mecme.org Enclosed is my check payable to Continuing Medical Education Or charge my Visa    MasterCard    AMEX Card #                                                                           /           /                                                                                       Exp. Date Signature