SEEEG Annual Meeting Registration Form

Registration Form
2011 Program


"Life is short, the art is long." - Hippocrates

Annual Meeting Registration Form

To register for the Annual Meeting, please fill out the form below and press the "Submit Registration" button. Or, If you prefer, please include all of the information below in an email and send it to: ursulink@uab.edu

Meeting registration fee:
SEEEG Members - $75.00
Nonmembers - $125.00

Please make checks payable to the:
Southern Epilepsy & EEG Society and mail to 1719 6th Avenue South, Suite 312, Birmingham, Alabama 35294.

* indicates required information.

First Name*:
Last Name*:
Degree*:
Affiliation*:
Mailing Address* :
City*:
State*:
Zip Code* :
Country*:
Phone:	( ) -
Fax:	( ) -
Email*:
Number of Guests* :