IMANA-Hofstra Ethics Symposium, Hempstead, NY,

September 17-18, 2010

Registration Form
NOTE: Print clearly using only a black or blue pen. Any field marked with an asterisk (*) is a required field.
You may also register on-line at http://bit.ly/REGISTER-IHE. For more information on the conference, visit
http://ethics2010.imana.org. Call IMANA at (630) 932-0000 with any questions.

Name (as it appears in official identification) *: ___________________________________________________

Mailing Address*: __________________________________________________________________________

City*: _____________________ State/Province*: _________ Zip*: ________________

Country*: __________________ E-mail*: _____________________________________

Phone*: ____________________________________

Check the day or days you plan to attend in the row which best describes you, then calculate the net fees.

9/17 Price 9/18 Price

Speakers, Hofstra faculty and students, all medical
students □ Free
IMANA Life Member Physicians □ $50 □ $50

IMANA Member Physicians □ $75 □ $75

Other Physicians □ $100 □ $100

Non-Physicians □ $25 □ $25

Physicians in training (Fellows and Residents),
Chaplains, other students □ $25
Total fees
Discount 20% if Sent Before
September 1, 2010 - ____
Net fees
 Payment
Total Amount Enclosed $______ Net fees must be paid in full.

Payment Method:
□ CHECK (payable to IMANA)
□MC □ VISA □ AMEX □ DISCOVER

Name as it appears on the card. _____________________________________

Card Number: ___________________________________

Valid Thru: ___/____ (mm/yy)

Signature: _____________________________________

Billing Address (if different from Mailing Address)

_______________________________________________________________________

_______________________________________________________________________

CMEs
Credit Designation
The Islamic Medical Association of North America (IMANA) and the Dodge County Medical Society of
Wisconsin designate this educational activity for a maximum of 13 AMA PRA ™ Category I Credit(s).
Physicians should only claim credit commensurate with the extent of their participation in the activity.
Accreditation:
The Dodge County Medical Society of Wisconsin is accredited by the Wisconsin Medical Society (WMS) to
provide continuing medical education (CME) for physicians. The Islamic Medical Association of North
American and the Dodge County Medical Society take responsibility for the content, quality and scientific
integrity of this CME activity.

□ I want to receive the CMEs offered.

Form Submission
Mail enclosed registration form and check payable to IMANA, if applicable, to IMANA, 101 W. 22nd Street,
Suite 106, Lombard, IL 60148 or fax the form to (630) 932-0005.