Title of Your Clinic

Brief Description of Your clinic

"Mainline" or "Shortline"

If Mainline, what equipment do you need?

(specify 35mm slides or digital)

Your Name

Your Division

Your Address

Telephone (Home or Cell?)

Email Address

Decision to accept and notification will be made no later than January 1, 2011.
Tentative time schedules will be available shortly thereafter.
All clinicians are strongly encouraged to provide written material for handouts
themselves (convention cannot provide such service).