2011 HVOS Fall Seminar Registration Form

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Please register early for the seminar and make your hotel reservations as early as possible. For hotel reservations please call the Poughkeepsie Grand Hotel at (845) 485-5300. Conference registration must be accompanied by full payment and includes the lectures, luncheon, refreshment breaks, admission to the exhibits and 5 C.E. credits for the doctors program. Advanced registration deadline is October 7th, 2011. Sign in begins at 8:00AM on October 21, 2011.

Registration Fees	before 10/07/2011	after 10/07/2011
AOA or AOS Members	$165	$190
Non-AOA/AOS Members	$195	$220
First Assistant	$55	$80
Second Assistant	$40	$65
Additional Assistants	$30	$55
Optometric Residents/Students*	$55	$80
Students/Residents without lunch	$25	$50

*student ID required

Please print names of persons attending below followed by the appropriate fees:

Name	Fee
1
2
3
4
5
6
7
	Total

Dr's Email_________________________________________________________________

Address___________________________________________________________________

City, State, Zip____________________________________________________________

Phone ( )___________________________________________________________

OE Tracker #______________________________________________________________

Please make check payable to HVOS and mail back with this form to:

2011 HVOS Fall Seminar Registration Form

Robert Greenbaum, OD, President HVOS

1110 Route 55

Lagrangeville, NY 12540

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