Please copy, paste, print out form to complete. Send form along with check to the address on form. We look forward to seeing you at our next events.

Management of Anterior Segment Inflammation: Clinical Case Studies

San Joaquin Optometric Society CE Registration Form

CE Event:  “Clinical Case Studies in Management of Anterior Segment

                  Inflammation”                                        

Speaker: Dr. Jeff Ing, M.D.

Date and Time:  Monday, August 16^th, 2010 @ 6:30 PM

Location:                    Papapavlo’s

                                    501 N. Lincoln Center

                                    Stockton, CA 95207

                                    209.477.6133                                                                       

Name:___________________________________________________

Email:___________________________________________________

Contact Phone:_________________________   Check #:___________           

To reserve your seat, please send the top portion of this form with your check to:

                 Pahoua Vue

                 473 Brookdale Dr

.                Merced, CA 95340

      ($35 for members/$52 for non-members, Please make checks payable to "SJOS")

All checks must be received by Monday, August 9th.

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CE Event:  “Clinical Case Studies in Management of Anterior Segment                 Inflammation”                                        

Speaker: Dr. Jeff Ing, M.D.

Date and Time:  Monday, August 16^th, 2010 @ 6:30 PM

Location:                    Papapavlo’s

                                    501 N. Lincoln Center, Stockton, CA 95207

                                    209.477.6133           

Name:___________________________________Check #:____________

Menu selection will be made that evening. SJOS society members will have their $35 check refunded at the CE event. Please keep this bottom portion for your records.  This is NOT a CE credit receipt. CE credit receipts will be distributed at the CE event. This course is pending COA approval for 2 CE credits.