february 2012 asipp® educational services meeting brochures/2012/0212...oak road, paducah, ky...

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COMPREHENSIVE REVIEW COURSE AND CADAVER WORKSHOP (BASIC, INTERMEDIATE, AND COMPREHENSIVE INTERVENTIONAL PAIN MANAGEMENT EXAMINATION PREPARATION COURSE) SUBMITTED FOR UP TO 20.25 AMA PRA CATEGORY ™1 CREDITS™ Phoenix — Arizona’s urban heart and America’s sunniest metropolis. Projected against this rich backdrop is a panorama of urban sophistication: Resorts and spas that drop jaws and soothe souls. Stadiums and arenas worthy of the world’s biggest sports spectacles. Restaurants with inspired cuisine and inspiring patio views. Golf courses that beckon players the year round. Shopping centers as stylish and eclectic as the fashions they house. The Cadaver Lab, Science Care, sets the standard of excellence for the donation and responsible use of human tissue for medical research, training and professional education. Science Care is the only organization to be accredited by both the American Association of Tissue Banks (AATB) and accredited as a provider by the Accreditation Council for Continuing Medical Education (ACCME). We have a fully audited quality assurance program, and insist on the highest standards not only for us, but for the vendors and clients that we work with. FEBRUARY 24-26, 2012 | PHOENIX, ARIZONA HOTEL & REVIEW COURSE LOCATION: Pointe Hilton Squaw Peak Resort 7677 North 16th Street, Phoenix, Arizona P: 602.997.2626 F: 602.997.2391 CADAVER WORKSHOP LOCATION: Science Care 2020 W. Melinda Lane, Phoenix, AZ 85027. P: 800.417.3747. F: 623.587.9800. Email: [email protected] SPECIALS: • $100 for Interventional Techniques in Chronic Spinal Pain and Chronic Non-Spinal Pain at Meeting for Attendees • 10% off Pre-Order of New Books: Foundations, Clinical Aspects, and/or Board Review Self-Assessment available in hard copy and DVD • 50% Off Meeting Fee to Fellows & Residents • Special room rates until February 2, 2012 American Society of Interventional Pain Physicians e Voice of Interventional Pain Management since 1998 ASIPP® Educational Services EXCELLENCE IN EDUCATION OF INTERVENTIONAL PAIN PHYSICIANS FEBRUARY 2012

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Page 1: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

COMPREHENSIVE REVIEW COURSE AND

CADAVER WORKSHOP(BASIC, INTERMEDIATE, AND COMPREHENSIVE INTERVENTIONAL

PAIN MANAGEMENT EXAMINATION PREPARATION COURSE)SUBMITTED FOR UP TO 20.25 AMA PRA CATEGORY ™1 CREDITS™

Phoenix — Arizona’s urban heart and America’s sunniest metropolis. Projected against this rich backdrop is a panorama of urban sophistication: Resorts and spas that drop jaws and soothe souls. Stadiums and arenas worthy of the world’s biggest sports spectacles. Restaurants with inspired

cuisine and inspiring patio views. Golf courses that beckon players the year round. Shopping centers as stylish and eclectic as the fashions they house. The Cadaver Lab, Science Care, sets the standard of excellence for the donation and responsible use of human tissue for medical research,

training and professional education. Science Care is the only organization to be accredited by both the American Association of Tissue Banks (AATB) and accredited as a provider by the Accreditation Council for Continuing Medical Education (ACCME). We have a fully audited quality

assurance program, and insist on the highest standards not only for us, but for the vendors and clients that we work with.

FEBRUARY 24-26, 2012 | PHOENIX, ARIZONA HOTEL & REVIEW COURSE LOCATION:

Pointe Hilton Squaw Peak Resort7677 North 16th Street, Phoenix, Arizona

P: 602.997.2626 F: 602.997.2391

CADAVER WORKSHOP LOCATION:Science Care

2020 W. Melinda Lane, Phoenix, AZ 85027. P: 800.417.3747. F: 623.587.9800. Email: [email protected]

SPECIALS:• $100 for Interventional Techniques in Chronic Spinal Pain and Chronic Non-Spinal Pain at Meeting for Attendees

• 10% off Pre-Order of New Books: Foundations, Clinical Aspects, and/or Board Review Self-Assessment available in hard copy and DVD• 50% Off Meeting Fee to Fellows & Residents

• Special room rates until February 2, 2012

American Society of Interventional Pain PhysiciansThe Voice of Interventional Pain Management since 1998

ASIPP® Educational ServicesEXCELLENCE IN EDUCATION OF INTERVENTIONAL PAIN PHYSICIANS

FEBRUARY 2012

Page 2: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

COMPREHENSIVE REVIEW COURSE AND CADAVER WORKSHOP(BASIC, INTERMEDIATE, AND COMPREHENSIVE INTERVENTIONAL PAIN MANAGEMENT EXAMINATION PREPARATION COURSE)FEBRUARY 24-26, 2012 | PHOENIX, ARIZONA

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS2

FROM THE CHAIRMAN

On behalf of the American Society of Interventional Pain Physicians and the ASIPP

Board of Directors, I am pleased to offer this unique educational event that can

assist you in furthering your knowledge-base and skills in the

specialty of Interventional Pain Management. This unique

course is designed for and dedicated to offering the highest

level of education, training, and measurement of skills in our

goal to provide better care and access for our patients.

The Comprehensive Review Course and Cadaver Workshop

is designed to meet the unique needs of interventional

pain physicians. With our excellent participant/instructor ratio, you will have the

opportunity for personal interaction with our highly distinguished faculty of world-

renowned teachers and lecturers, creating a thorough and compelling educational

experience.

During the 2½-day Comprehensive Review Course and Cadaver Workshop, you

can improve existing skills and/or learn new techniques. Whether you have been

practicing interventional pain management for many years or are new to the

field with basic skills, we are confident you will find this course and workshop

to be beneficial – as it is essential that we continue learning and exploring new

procedures and techniques in our specialty.

We are confident that you will benefit from this exceptional opportunity for

professional enhancement. This seminar will be conducted at The Science Care

facility in Phoenix, Arizona and accommodations will be at the Pointe Hilton Squaw

Peak resort. Make your plans early to attend. We look forward to seeing you in

Phoenix. If you have any questions, please feel free to contact me at 2831 Lone

Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or

e-mail: [email protected]

Sincerely,

Laxmaiah Manchikanti, MD

Chairman of the Board and Chief Executive Officer, ASIPP

American Society of Interventional Pain Physicians®THE VOICE OF INTERVENTIONAL PAIN MANAGEMENT SINCE 199881 Lakeview Drive, Paducah, KY 42001Phone: 270.554.9412 Fax: 270.554-5394E-Mail: [email protected] Site: www.asipp.org

CHIEF EXECUTIVE OFFICER AND CHAIRMAN OF THE BOARDLaxmaiah Manchikanti, MD—Paducah, KYPRESIDENT Standiford Helm II, MD—Laguna Hills, CA IMMEDIATE PAST PRESIDENTAllan T. Parr, MD—Covington, LA PRESIDENT-ELECTFrank J.E. Falco, MD—Newark, DE FIRST EXECUTIVE VICE PRESIDENTHans C. Hansen, MD—Conover, NCSECOND EXECUTIVE VICE PRESIDENTRamsin M. Benyamin, MD—Bloomington, ILVICE PRESIDENT STRATEGIC PLANNINGDavid L. Caraway, MD, PhD—Huntington, WVSECRETARYSukdeb Datta, MD—Summit, NJ TREASURERAaron K. Calodney, MD— Tyler, TX

LIFETIME DIRECTORSCyrus E. Bakhit, MD—Roanoke, VALaxmaiah Manchikanti, MD—Paducah, KYBentley A. Ogoke, MD—Mount Vernon, NY Vijay Singh, MD—Niagara, WI

DIRECTORS AT LARGEMark V. Boswell, MD, PhD—Louisville, KY David Bryce, MD—Middleton, WIScott E. Glaser, MD—Burr Ridge, ILHaroon Hameed—Baltimore, MDRodney L. Jones, MD—Wichita, KSDavid S. Kloth, MD—Danbury, CTGabor B. Racz, MD—Lubbock, TXFrancis Reigler, MD—Malibu, CAXiulu Ruan, MD—Mobile, ALDavid M. Schultz, MD—Minneapolis, MN Peter S. Staats, MD—Shrewsbury, NJJohn R. Swicegood, MD—Fort Smith, AR

DIRECTORS EMERITUSW. Stephen Minore, MD—Love Park, ILJoshua A Hirsch, MD—Boston, MA

PAIN PHYSICIAN EDITOR-IN-CHIEFHoward S. Smith, MD—Albany, NY

AMA DELEGATESLaxmaiah Manchikanti, MD—Paducah, KYLee Snook, MD—Sacremento, CA

STAFFMelinda Martin, Director of OperationsRay Lane, Director of Public RelationsHolly Long, Coordinator of Editorial ServicesVidyasagar Pampati, Statistician and ProgrammerMolly White, Editorial AssistantPaula Reynolds Spear, Meeting CoordinatorTom Prigge, Multimedia SpecialistCindy Rogers, Administrative Assistant

GOVERNMENT AFFAIRS COUNSELSenator Tim Hutchinson and Randi Hutchinson, Esq Dickstein Shapiro, LLP1825 Eye Street NWWashington, DC 20006 · 202.420.3600 [email protected]

GENERAL COUNSELErin Brisbay McMahon, JDWyatt, Tarrant & Combs, LLP250 West Main Street, Suite 1600Lexington, KY 40507 · [email protected]

Page 3: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

COMPREHENSIVE REVIEW COURSE AND CADAVER WORKSHOP(BASIC, INTERMEDIATE, AND COMPREHENSIVE INTERVENTIONAL PAIN MANAGEMENT EXAMINATION PREPARATION COURSE)

FEBRUARY 24-26, 2012 | PHOENIX, ARIZONA

AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS 3

DESCRIPTION, PURPOSE AND TARGET AUDIENCE

This 2½-day review course and workshop is designed for interventional pain physicians, for a review, skills improvement or to assist in preparation for Comprehensive Interventional Pain Management Examination qualifications. ASIPP offers the most in-depth, comprehensive, and individualized programs available in interventional pain management, featuring maximum hands-on training with cadavers in a state-of-the-art facility and maximum ability to interact with other participants. Participants will experience a comprehensive and intense learning opportunity, focusing on interventional pain management techniques.

• Each cadaver station is limited to a maximum of 8 participants.

• Participants can choose the level of participation: basic, intermediate, or Comprehensive Interventional Pain Management Examination Preparation Course.

• C-arms and state-of-the-art equipment are utilized in this course. Participants are requested to dress in casual attire or scrubs. Leaded aprons and thyroid shields will be provided. However, participants are advised to bring their own protective eyewear.

The workshop is offered to improve the delivery of multiple aspects of interventional pain management. The desired outcome is to integrate multiple aspects of interventional pain management in treating your patients so that patients have better outcomes and reduced side effects.

OUTCOME

Physicians should be able to integrate multiple aspects of interventional pain management techniques in patient treatments so that patients have better outcomes and reduced side effects.

ACCREDITATION AND CME CREDIT STATEMENTS

This CME activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education thru the Joing Sponsorship of the Institute for Medical Studies (IMS) and ASIPP. IMS is accredited by the ACCME to provide continuing medical education for physicians.

The Institute for Medical Studies designates this educational activity for a maximum of 20.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AMERICANS WITH DISABILITIES ACT & SPECIAL SERVICES

Organizers fully comply with the legal requirements of the Americans with Disabilities Act and the rules and regulations thereof. If any participant in these educational activities is in need of accommodations, please contact the organizers at (270) 554-9412 at least 10 days prior to each conference.

CADAVER WORKSHOP SITE

Science Care sets the standard of excellence for the donation and responsible use of human tissue for medical research, training and professional education. Science Care is the only organization to be accredited by both the American Association of Tissue Banks (AATB) and accredited as a provider by the Accreditation Council for Continuing Medical Education (ACCME).

ACCOMMODATIONS

POINTE HILTON SQUAW PEAK RESORT7677 North 16th Street, Phoenix, ArizonaTel: 1-602-997-2626 Fax: 1-602-997-2391

Nestled into the slopes of the Phoenix North Mountains is the Pointe Hilton Squaw Peak Resort. This 563-suite resort offers unparalleled ambiance and personal service. The Resort is home to the Hole-in-the-Wall River Ranch - a water wonderland with acres of pools and a putting course; Tocasierra Spa, Salon & Fitness; tennis; Coyote Camp™ - children’s program; themed dining establishments; access to the Lookout Mountain Golf Club; and more. Inform the agent that you are booking for ASIPP. We have secured a group room rate of $160. Reserve rooms early—all unbooked rooms will be released February 2, 2012.

THERE IS NO COMMERCIAL SUPPORT FOR THIS COURSE. No duplication or distribution of materials, or recording of lectures associated. There is NO commercial support for this course.

Page 4: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

4

CADAVER LAB – SATURDAY AND SUNDAY

LAB COURSE LEVELS

BASIC

1. Caudal epidural injections

2. Lumbar interlaminar epidural injections

3. Lumbar transforaminal epidural injections

4. Sacroiliac joint interventions

5. Lumbar facet joint intraarticular injections

6. Lumbar facet joint nerve blocks

7. Lumbar facet radiofrequency neurotomy

INTERMEDIATE

1. Lumbar discography

2. Lumbar sympathetic blocks and hypogastric plexus blocks

3. Celiac plexus blocks and splanchnic nerve blocks

4. Cervical and thoracic interlaminar epidurals

5. Thoracic facet interventions (intraarticular, medial branch

blocks, and radiofrequency neurotomy)

6. Cervical facet joint interventions (intraarticular, medial

branch blocks, and radiofrequency neurotomy)

7. Percutaneous adhesiolysis

COMPREHENSIVE INTERVENTIONAL PAIN MANAGEMENT EXAMINATION PREPARATION

1. Caudal epidural, interlaminar epidural, and percutaneous adhesiolysis

2. Lumbar transforaminal and lumbar discography

3. Lumbar facet joint interventions (intraarticular, facet joint nerve

blocks, intercostal blocks, and radiofrequency neurotomy) and

sacroiliac joint injections

4. Thoracic facet joint interventions (medial branch blocks and

radiofrequency neurotomy), intercostal nerve blocks, and thoracic

interlaminar epidural injections

5. Cervical facet joint interventions (medial branch blocks

and radiofrequency neurotomy) and cervical interlaminar

epidural injections

6. Spinal cord stimulation lead placement

7. Sympathetic blockade (stellate ganglion, lumbar

sympathetic blocks and celiac plexus blocks)

7:00am–8:00am REGISTRATION AND BREAKFAST AT HOTEL

8:00am–8:45am Introduction to ASIPP and Board Course and Workshop -Laxmaiah Manchikanti, MD

8:45am–9:30am Imaging for Interventionalists – Fluoroscopy, Radiation Safety, and Needle Placement - Frank Falco, MD

9:30am–10:15am An Algorithmic Approach to interventional Pain Management: Evidence Based or Comparative Effectiveness? - Laxmaiah Manchikanti, MD

10:15am–10:45am BREAK

BREAKOUT SESSIONS ON FOLLOWING PAGE > > >

COMPREHENSIVE DIDACTIC REVIEW COURSE

FRIDAY FEBRUARY 24, 2012

Page 5: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

5

BREAKOUT SESSIONS

BASIC INTERMEDIATE IPM EXAM PREP

BASIC AND INTERMEDIATE LECTURES COVER: HISTORY, CLINICAL PRESENTATION, RELEVANT ANATOMY, TECHNICAL ASPECTS, COMPLICATIONS, EVIDENCE, AND PATIENT SELECTION OF EACH INTERVENTION

10:45am–11:30amCaudal Epidural Injections

Vikram Patel, MD

Lumbar Discography

Aaron Calodney, MD

Introduction to ABIPP

Laxmaiah Manchikanti, MD

11:30am–12:15pm

Lumbar Interlaminar Epidural injections

Frank Falco, MD

Lumbar Sympathetic and Hypogastric Plexus Blocks

Miles Day, MD

Drug TherapyFor Chronic Pain

Rafeal Justiz, MD

12:15pm–1:15pm LUNCH

1:15pm–2:00pmSacroiliac Joint Interventions

Vikram Patel, MD

Celiac Plexus and Splanchnic Nerve Blocks

Standiford Helm, MD

Lumbar Axial Pain:Case Presentations

Ramsin Benyamin, MD

2:00pm–2:45pm

Lumbar Transforaminal Epidural Injections

Miles Day, MD

Cervical and Thoracic Interlaminar Epidurals

Rafeal Justiz, MD

Lumbar Radicular Pain and Post Laminectomy Syndrome:

Case Presentations

Frank Falco, MD

2:45pm–3:15pm BREAK

3:15pm–4:00pm

Lumbar Facet Radiofrequency Neurotomy

Frank Falco, MD

Thoracic Facet Joint Interventions (Intraarticular, Medial Branch Blocks, and

Radiofrequency Neurotomy)

Vikram Patel, MD

Cervical and Thoracic Axial Pain:Case Presentations

Standiford Helm, MD

4:00pm–4:45pmLumbar Facet Joint Injections

Rafeal Justiz, MD

Cervical Facet Joint Interventions (intraarticular, medial branch blocks, and

radiofrequency neurotomy)

Aaron Calodney, MD

Cervical and Thoracic Radicular Pain, Post Laminectomy Syndrome, and Intercostal:

Case Presentations

Ramsin Benyamin, MD

4:45pm–5:45pm

Troubleshooting and Complications for Beginners

Ramsin Benyamin, MD

Percutaneous Adhesiolysis

Standiford Helm, MD

Complex Regional Pain Syndrome (CRPS)and Abdominal Pain: Case Presentations

Miles Day, MD

COMPREHENSIVE DIDACTIC REVIEW COURSE

FRIDAY FEBRUARY 24, 2012

No duplication or distribution of materials, or recording of lectures associated with this conference is permitted without express written consent of the American Society of Interventional Pain Physicians. All rights reserved.

Page 6: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

6

6:45am–7:00am SHUTTLES DEPART FROM FROM THE HOTEL TO THE CADAVER FACILITY

7:00am–7:45am REGISTRATION AND BREAKFAST

7:45am–8:30am Introduction Standiford Helm, MD

8:30am–12:00pm HANDS-ON CADAVER WORKSHOPParticipants rotate through multiple stations

12:00pm MEETING ADJOURNMENT. SHUTTLES DEPART FROM CADAVER FACILITY TO HOTEL AND TO THE AIRPORT.

6:45am–7:00am SHUTTLES DEPART FROM FROM HOTEL TO THE CADAVER FACILITY

7:00am–7:45am REGISTRATION AND BREAKFAST

7:45am–8:30am Introduction Ramsin Benyamin, MD

8:30am–1:00pm HANDS-ON CADAVER WORKSHOPParticipants rotate through multiple stations

1:00pm–2:00pm LUNCH PROVIDED

2:00pm–5:00pm HANDS-ON CADAVER WORKSHOPParticipants rotate through multiple stations

5:00pm SHUTTLES DEPART FROM CADAVER FACILITY TO THE HOTEL

HANDS-ON CADAVER WORKSHOP

SATURDAY FEBRUARY 25, 2012

HANDS-ON CADAVER WORKSHOP

SUNDAY FEBRUARY 26, 2012

Page 7: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

7

REGISTRATION FORMREGISTRATION INFORMATIONPlease complete the enclosed registration form and return to ASIPP with payment (your application will not be processed if payment does not accompany registration form). ASIPP reserves the right to cancel this Workshop and/or Review Preparation Course upon reasonable notice and will assume no financial obligation to registrants for cancellation of the course for reasons beyond its control. Registration fees will be refunded. However, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants.Registrants who are not accepted into this workshop will receive notice by mail with their returned checks.

IMPORTANT: Please answer all the questions:

PRIMARY SPECIALTY CERTIFICATION:m Anesthesiology m Physiatrym Neurosurgery m Other: _______________________________________PAIN MEDICINE SUBSPECIALTY CERTIFICATION:m American Board of Anesthesiologym American Board of Pain Medicinem American Board of Interventional Pain Physicians m Fellow of Interventional Pain Practice (FIPP)SPECIALTY DESIGNATION:m 09 - Interventional Pain Managementm 72 - Pain Managementm Other: _______________________________________PERCENTAGE OF INTERVENTIONAL PAIN MANAGEMENT PRACTICE:m 0% m 1-25% m 26-50% m 51-75% m > 75%YEARS IN INTERVENTIONAL PAIN MANAGEMENT PRACTICE:m 0 m 1-5 m 6-10 m > 10PLEASE SELECT ONE OF THE FOLLOWING:m Basic m Intermediate m ABIPP Exam PrepTOTAL NUMBER OF PROCEDURES PERFORMED DURING PAST YEAR: ASC HOPD OFFICE

Caudal Epidural _____ _____ _____Stellate Ganglion Blocks _____ _____ _____Thoracic Sympathetic Blocks _____ _____ _____Lumbar Discography _____ _____ _____Sacral Transforaminal Epidural _____ _____ _____Lumbar Sympathetic Blocks _____ _____ _____Caudal Epidural _____ _____ _____Lumbar Facet Joint Blocks _____ _____ _____Thoracic Interlaminar Epidural _____ _____ _____Cervical Interlaminar Epidural _____ _____ _____Cervical Facet Joint Blocks _____ _____ _____Cervical Radiofrequency _____ _____ _____Thoracic Joint Blocks _____ _____ _____Thoracic Radiofrequency _____ _____ _____Lumbar Radiofrequency _____ _____ _____Lumbar Transforaminal Epidural _____ _____ _____Hypogastric Plexus Blocks _____ _____ _____Sacroiliac Joint Injections _____ _____ _____Pyriformis Block _____ _____ _____Percutaneous Adhesiolysis _____ _____ _____

PLEASE PRINT EXACTLY AS YOU WISH YOUR NAME TO APPEAR:

________________________________________________________________________________________________NAME (FIRST) (MIDDLE INITIAL) (LAST) (DEGREE)

________________________________________________________________________________________________ORGANIZATION

________________________________________________________________________________________________ADDRESS

________________________________________________________________________________________________CITY STATE ZIP

________________________________________________________________________________________________PHONE CELL FAX

________________________________________________________________________________________________EMAIL

REGISTRATION FEE FOR COMPREHENSIVE REVIEW COURSE AND CADAVER WORKSHOPEarly Bird - On or before February 2, 2012: m $2,200 Member m $2,500 Non-MemberRegular - After February 2, 2012: m $2,500 Member m $2,800 Non-Member

SPECIAL RATES FOR FELLOWS AND RESIDENTSEarly Bird - On or before February 2, 2012: m 50% offRegular - After February 2, 2012: m 50% off

PAYMENT METHOD (Please check one):m MASTERCARD m VISA m AMERICAN EXPRESS m DISCOVER m CHECK

______________________________________________________________________________________________CREDIT CARD NUMBER SECURITY CODE (Back of Card) EXP. DATE

______________________________________________________________________________________________NAME ON CARD

______________________________________________________________________________________________AUTHORIZED SIGNATURE (required on all credit card orders)

________________________________________________________ m ENCLOSED (Payable to ASIPP)CHECK NUMBER(Your application will not be processed if payment does not accompany registration form)

RETURN COMPLETED FORM TO:ASIPP, 81 Lakeview Drive, Paducah, KY 42001 or Fax to (270) 554-5394

THREE WAYS TO REGISTER 1. ON-LINE: For convenience and faster registration, register at www.asipp.org/meetings

2. FAX: Fax this registration form to 270.554.5394 with your Visa/MasterCard/ Discover/American Express information

3. MAIL: Mail this registration form with payment —check or Visa/MasterCard/Discover/American Express information— to: ASIPP, 81 Lakeview Drive, Paducah, KY 42001

CANCELLATION POLICY:ASIPP reserves the right to cancel this course upon reasonable notice and will assume no financial obligation to registrants for cancellation for reasons beyond its control. Registration fees will be refunded. However, costs incurred by the registrants, such as airline or hotel fees or penalties, are the responsibility of the registrants. ASIPP requires a 30-day notice of cancellation. Cancellations must be submitted in writing by January 25, 2012. An administrative fee of $200 will be assessed. Cancellations after January 25, 2012 but prior to February 9, 2012, will forfeit 50% of their registration fee. No cancellations accepted after February 9, 2012. Refunds will be sent after the conclusion of the meeting.

Page 8: FEBRUARY 2012 ASIPP® Educational Services meeting Brochures/2012/0212...Oak Road, Paducah, KY 42003, phone: 270-554-8373 ext. 101, fax: 270-554-5394, or e-mail: drm@asipp.org Sincerely,

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