Hot Topics in Trauma 2012 Registration - March 30, 2012

In order for this form to be properly processed please print out the form, fill out the section
below and mail it in its entirety (along with payment) to:       

NIEC - Hot Topics
PO Box 11176
Philadelphia, PA 19136

Tuition (check one or more):  ____ Physicians $195.00  ___ All others $145.00

Make checks payable to: "NIEC"

Name:___________________________________________________________________

Address:_________________________________________________________________

City:________________________________________ State:_____ Zip:______________

Phone (Day):____________________________ (Evening):________________________

Check one:  ___ MD/DO ___ EMT-P ___ EMT ___ PHRN ___ Other:___________

Please provide the last 4 digits of your SS#. This will allow web access to your CME transcript
at any time after the course ________________.

For room reservations call Bally's at 1-800-345-7253.  Mention the NIEC conference to receive a
preferred room rate.

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