Fourth Annual Chicago Supportive Oncology Conference - October 15-18, 2008 - (Page 7)

er e! st v gi S a Re y & rl Ea October 15-18, 2008 First Name Professional title Afﬁliation/Institution Address (billing) Address 2 City State Zip + 4 digit postal code Country Last Name Hotel InterContinental �� Sufﬁx/Degree Telephone (do not include international dialing code) Fax (do not include international dialing code) E-mail PRIVACY POLICY: We collect these data to provide you with information about the Chicago Supportive Oncology Conference and other organizations in your ﬁeld. If you prefer not to receive further information, please contact w.mcgullam@elsevier.com. WHAT IS YOUR PROFESSION: Physician (MD/DO) Physician Assistant Nurse Practitioner Nurse Pharmacist Other WHAT IS YOUR SPECIALTY: Medical Oncology Hematology-Oncology Hematology Radiation Oncology Pain & Palliative Medicine Internal Medicine Other WHAT IS YOUR AREA OF INTEREST: Brain Cancer Breast Cancer Gastrointestinal Malignancies Genitourinary Malignancies Gynecological Malignancies Head & Neck Cancer Hematological Malignancies Lung Cancer Melanoma/Sarcoma Supportive Care Other PLEASE TELL US HOW YOU LEARNED ABOUT THIS CONFERENCE: Advertising Postal Mail eMail Web Site Trade Show Colleague Other 3 WAYS TO REGISTER: Online: Fax: Mail: It’s fast, easy, and reliable: www.supportiveoncology.net/chicago Complete this form and fax to 631-424-8905 Complete this form and mail to: Chicago Supportive Oncology Conference, c/o Elsevier Inc, 46 Green Street, 2nd Floor, Huntington, NY 11743. Questions: Call 631-424-8900 ext 323 CONFERENCE REGISTRATION FEE Early Bird on or before 8/31/08 Physician Resident, Fellow, Physician Assistant, Nurse Practitioner, Nurse, Pharmacist Industry METHOD OF PAYMENT: Enclosed is check # made payable to: Elsevier, Inc. Mail check to Chicago Supportive Oncology Conference, c/o Elsevier Inc, 46 Green St, 2nd Floor, Huntington, NY 11743. Charge my (check one) VISA MASTERCARD AMEX After 8/31/08 $295 $195 $395 $195 $95 $295 Account Number Expiration Date Signature ( I agree to pay the total amount according to my card issuer agreement.) Cardholder’s Name (please print ) CANCELLATION POLICY: Registrants who do not cancel according to the following guidelines will forfeit all registration fees. You must write, email, or fax your cancellation request. There is a registration cancellation fee of 50% of your registration rate for cancellations received on or before August 31, 2008. There are no refunds for cancellations after August 31, 2008. “No shows” are not eligible for refunds. Registration refunds will be processed within 60 days following the meeting. SPECIAL NEEDS STATEMENT: We encourage participation by all individuals. If you have any special needs, advance notiﬁcation will help us better serve you. Please contact Wendy McGullam at least two weeks in advance at 631-424-8900 ext 323, or e-mail w.mcgullam@elsevier.com. http://www.supportiveoncology.net/chicago

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Fourth Annual Chicago Supportive Oncology Conference - October 15-18, 2008

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