Gi Nurse, Technician Or Associate Registration Form

GI NURSE, TECHNICIAN OR ASSOCIATE REGISTRATION FORM

STEP 1: Type or Print All Contact Information

Name: / Date:
Address: / Credentials:
City, State, Zip: / Country, if not USA
Email Address: / Fax:
Phone: / Cell Phone (optional):

STEP 2: Circle Annual New York Course Registration Fee

Circle Applicable Fee / By
November 7 / November 8
to December 5 / On or After
December 6
GI Nurse, Technician or Associate / $425 / $475 / $575

STEP 3: Circle Optional Satellite Program Fee(s)

Optional Satellite Programs
Wednesday, December 13, 2017 / By
November 7 / November 8
to December 5 / On or After
December 6
Option 1: Esophageal Workshop / 12:45 pm-6:00 pm / $100 / $150 / $200
Option 2: Bariatrics Workshop / 1:15 pm-7:00 pm / $100 / $150 / $200
Option 3: Viral Hepatitis and Nonalcoholic Fatty Liver Disease Symposium / 6:00 pm-9:00 pm / $50 / $60 / $70
Optional Satellite Programs
Thursday, December 14, 2015 / By
November 7 / November 8
to December 5 / On or After
December 6
Option 4: Advanced Capsule Workshop / 5:45 pm-9:30 pm / $100 / $150 / $200
Option 5: Advanced Therapeutic Endoscopy Techniques / 5:45 pm-9:00 pm / $100 / $150 / $200

STEP 4: Special Dietary Needs

1.  We offer three special meal options. If applicable, please check your preference.

_____ KOSHER

_____ GLUTEN-FREE

_____ VEGAN

2.  Indicate which day(s) you will require a special meal:

_____ Thursday

_____ Friday

3.  If you have needs other than those listed, please describe: ______

STEP 5: Payment Information

_____ Check Enclosed** Check Number: ______Total Payment Amount: ______

_____ Credit Card _____ American Express _____ Master Card

_____ Visa _____ Discover

Credit Card No.______Expiration Date (mm/yy): ______

CID (Security Code): ______Name as Printed on Card: ______

Billing Address: ______City/State: ______Zip Code______

Country (if outside of USA): ______Signature: ______

STEP 6: Submission Options

1.  Fax the entire 2-page registration form to: 866-381-7288

2.  Email the entire 2-page registration form to

3.  Mail check payment and entire 2-page registration form to:

NYSGE c/o DHW

3300 Woodcreek Drive

Downers Grove, IL 60515

**Please note: Forms and checks or credit card information must be RECEIVED by the last eligible date respective to the fee paid. Allow 2 weeks for mailed forms.

Name of person completing this form (if other than registrant): ______

Email ______Phone ______]

Cancellation Policy

Refund less $50 processing fee for Annual New York Course registration and for Options 1, 2, 4 and 5 will be given when requested in writing and submitted no later thanDecember 6, 2017. No refunds will be made after this date.A full refund for Option 3 will be given when requested in writing and submitted no later thanDecember 6, 2017. No refunds will be made after this date.