Echo Alaska Program Registration

This form will allow you to electronically register for the Echo Alaska Program. If you have not already registered for the cruise, please go back and click the Cruise Registration button. Please complete all information.

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Registration Information

First Name:

Middle Name or Initial:

Last Name:

Institution:

E-mail Address:

Which is your preferred mailing address? Work/Business Home

Street Mailing Address:

City:

State/PV:

Zip/Postal Code:

Country:

Telephone Number:

Fax Number:

Disability Accommodations? Yes If you need disability accommodations, please check the box and advise us of your needs at least two weeks before the program.

Tuition Information

	Tuition received on or before June 5, 2008	Tuition received after June 5, 2008
ASE Member	$450	$550
Physician Non-member	$550	$650
Reduced Fee*	$400	$500

* Registrants in the reduced fees category are required to submit with the registration form proof of licensure, a business card, or a letter written on official letterhead, and signed by a department supervisor verifying status. Reduced Fee includes: Fellow/Resident in Training, Physician Assistant, Nurse, Sonographer, or Emeritus Staff.

Payment

Payment must accompany registration.

Credit Card Check (payable to Ultra Echo Ltd. - Echo Alaska 2008 in US dollars drawn on a US bank)

Visa MasterCard Discover

Credit Card #:

CC Expires:

Name on CC:

3-Digit Security Code:(3 digits from back of credit card)

Please make checks payable to: Ultra Echo Ltd. - Echo Alaska 2008

Thank you for using Corporate Travel Solution's online registration system.