Registration Form Fourth Annual QMP Aesthetic Surgery Symposium September 4 - 7, 2008 at the Renaissance Chicago Hotel, Chicago, IL Name: __________________________________________________________ Address: ________________________________________________________ City: ________________________________ State: ______ Zip: __________ E-mail: ____________________________ Country______________________ Telephone: __________________________ Fax: _______________________ REGISTRATION FEES & DEADLINE       BEFORE 8/1/08     AFTER 8/1/08      Physician     $1400     $1500      Resident     $700     $800 MAKE CHECKS PAYABLE TO: Quality Medical Conferences Send your registration form to: Quality Medical Conferences 2248 Welsch Industrial Ct. St. Louis, MO 63146 USA Attn: Andrew Berger OR Fax your registration and credit card information to: (314) 878-9937 CANCELLATION POLICY: Registration is 50% refundable only if a written cancelation is received at QMP before August 1, 2008. No refunds will be given after August 1, 2008 for any reason. Payment (check one): Credit Card:   Discover   Visa   Mastercard   American Express Check Enclosed Card #: ____________________________ Exp. Date: ______ Verification #: _____ Print Card Holder's Name: _____________________________________ Signature: ____________________________________________________