Registration Form Fee Schedule Until 1/31/08 Until 3/7/08 After 3/7/08 Physician $695 $795 $895 Residents & Allied Health $695 $695 $695 Registrant Information First Name: Last Name: Degree: : MD : DO : RN : Resident : Other Specify: Specialty: choose speciality Gynecology Ob/Gyn Urology Urogynecology Other Affiliation/Practice Name: Street Address: Street Address 2: City: State/Province: select state ALAKABAZARBCCACOCTDEDCFLGAGQHIIDILINIAKSKYLAMEMBMDMAMIMNMSMOMTNENVNBNHNJNMNYNLNCNDNTNSNUOHOKONORPAPEPRQCRISKSCSDTNTXUTVTVIVAWAWVWIWYYT Zip/Postal Code: Country: select country United StatesAlgeriaArgentinaAustraliaAustriaBahamasBelgiumBermudaBoliviaBotswanaBrazilBulgariaCambodiaCanadaChileChinaColombiaCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkEcuadorEgyptEnglandFinlandFranceFrench GuyanaGermanyGreeceGuadalupeGuatemalaHollandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJapanJordanKenyaKoreaLebanonLuxembourgMalaysiaMaltaMexicoN. IrelandNepalNetherlandsNew ZealandNorwayPakistanPanamaPeruPhilippinesPolandPortugalQatarRomaniaRussiaSaudi ArabiaScotlandSingaporeSlovakiaSouth AfricaSpainSri LankaSwedenSwitzerlandTaiwanThailandTrinidadTunisiaTurkeyUnited Arab Em.United KingdomUruguayVenezuelaVietnamWest IndiesYugoslaviaZambia Email: Daytime Phone: Fax: Number of years in practice: : 1-5 : 6-10 : 11-15 : 16-20 : 20+ How did you learn about the Symposium? : Brochure by mail : Email invitation : Ad in a journal : Online banner ad : Colleague : Other How many years have you attended the Symposium? : First Time : Years