CCJR WINTER 2017 Course Registration Form

December 13 - 16, 2017
Orlando, Florida

COMODO SECURE

* = Required Entry

Participant Information

Please complete this section with information pertaining to the person attending the meeting.

Name will appear on course badge as (First Name / Last Name, Degree)

Registration Information

To register, please make the appropriate selection:

CCJR W2017
Surgeon - Nurse - Allied Health - Other
 $ 900 USD
CCJR W2017
Resident/Fellow-in-Training*
 $ 450 USD

* Currently enrolled in Residency Training Program. Program Director Certification required prior to meeting date. Email to: info@CCJR.com

You have registered for the CCJR Winter 2017 meeting at the Resident/Fellow Rate. You are required to submit a Program Director Certification letter indicating you are currently a resident/fellow and eligible for the reduced registration rate.

THIS LETTER IS REQUIRED AND MUST BE SUBMITTED by email (info@ccjr.com) or fax (216.295.9955) within one week.

Failure to submit will result in paying the full registration rate or cancellation of your registration.
Additional Contact
Billing Information

To complete this registration, the fee of $ --- USD must be paid by credit card or PayPal.

Choose a Payment Method:

To pay with your PayPal® account or create a PayPal® account, click the button to the right. This will open a new window in which you need to log into PayPal and confirm your payment arrangement. Once that's complete, you will be returned to this page to complete the registration process.

 

You will have an opportunity to review your information and make any necessary changes before submitting.