NERVES Event Registration


Name________________________________________ Title___________

Practice__________________________________________________________

AANS/CNS Physician Member _______________________________________

Address__________________________________________________________

City, State, Zip_____________________________________________________

Phone________________________________ Fax_______________________

E-mail___________________________________________________________


Please check which item applies:

___ I am a current NERVES member (or currently paying dues to become a member) and would also like to attend the annual meeting ($395.00, after April 6, 2010 - $445)

___ I am not a NERVES member but would like to attend the annual meeting ($495, after April 6, 2010 - $545.00)

Amount Enclosed _______________________ Check # __________________

Attach check made payable to NERVES and mail to:

NERVES
400 East Blvd.
Suite 210
Charlotte, NC 28203