REGISTRATION FORM (Please Print)

Seventh Annual Conference of the Center for Prostheses Infection (CPI)
and the
Multidisciplinary Alliance Against Device-Related Infections (MADRI)

 Name  (Last/First/Middle)
     Degree 
 Affiliation 
 Address 
 City 
     State         Zip Code
 Telephone
      Fax      
 Email

 Type of Registration:
Physicians
Nurses/Allied Health Professionals
 Residents/Fellows
Industry Reps

 Accompanying persons: (names)
 12 & Older:
   
  Under 12:
   

  Pre-Conference $
  Conference $
  Golf Tournament $
  Accompanying Persons (12 & up) $
  TOTAL $
 Yes, I will be participating in the 
         Scenic Sunrise Power Walk

         Number participating

PAYMENT METHOD (specify)
CHECK in the amount of   $     (in US funds made payable to BCM PMR) is enclosed.

Please charge my              VISA ®          MasterCard  ®     American Express  ®   
  CREDIT CARD NUMBER    EXPIRATION DATE (Month/Year)
   Name as it appears on the card (Please Print)  
   Signature   

Return completed registration form and payment (check or credit card information) to:
BCM Dept PMR
1333 Moursund
Houston, Texas 77030

Alternatively, registration paid by credit card can be faxed to: 713-799-5058. (Either fax or mail, but not both)

For More Information Contact:   Donna Jones (djones1pmr@aol.com) — 713.799.5086

Or Visit Our Website: www.maadrialliance.org