MMA 155th Annual Session

Registration

Red items are required. Please complete form for each participant.

First:
MI:
Last:
Title (MD, DO, etc.):
Company/Practice:
Address:
City:
State:
Zip:
Tel:
Fax:
Email:
(Email is to be used for conference purposes only)
Spouse/Guest name:
Children:

Conference Fees: (one item is required)

Thursday only [Quality Symposium] (7 CME) $100.00
Thursday - Sunday Quality Symposium & Annual Session (14 CME) $245.00
Friday - Sunday Full Annual Session Conference (7 CME) $145.00
Friday only (3.5 CME) $75.00
Saturday only (1.5 CME) $40.00
Sunday only (2 CME) $40.00

Conference Meals:			Children (under 12)
Fri. Lunch	$35.00	x	$10.00	x
Sat. Lunch	$35.00	x	$10.00	x
Sat. Banquet	$50.00	x	$25.00	x
Sun. Brunch	$0	x	$0	x

Additional Meetings I plan to attend:
Orthopedic Surgery
Kennebec County
Penobscot County
Urology
Psychiatric Physicians