Step 1: Please Type Or Print All Information

STEP 1: PLEASE TYPE OR PRINT ALL INFORMATION

Name: / Date:
Address: / Credentials:
City, State, Zip: / Country, if not USA:
Email Address: / Fax:
Phone: / Cell Phone (optional):

STEP 2: 39th Annual New York Course Registration – GI Fellow, Residentor, Medical Student

GI Fellows Must Be NYSGE Members. Membership Is Complimentary But An Application Is Required.

Visit to Apply Online.

Circle Appropriate Fee / By
November 10 / November 11 to December 8 / On or After
December 9
GI Fellow, Resident, or Medical Student / $450 / $500 / $600

STEP 3: Advanced Hands-On Workshops and Satellite Symposia Registration (Circle Fees for Desired Options)

Optional Program Information
Wednesday, December 16, 2015 / By
November 10 / November 11 to December 8 / On or After
December 9
Option 1: Esophageal Workshop / 12:45-7:15pm / $60 / $75 / $95
Option 2: MOC Course / 1:30-4:30pm
Option 3: Advanced Colon Workshop / 5:45-9pm / $60 / $75 / $95
Option 4: EUS Symposium / 6-8:30pm / $40 / $50 / $60
Option 5: IBD Symposium / 6-8:30pm / $40 / $50 / $60
Optional Program Information
Thursday, December 17, 2015 / By
November 10 / November 11 to December 8 / On or After
December 9
Option 6: Capsule Workshop / 5:30-10:30pm / $60 / $75 / $95
Option 7: ERCP Workshop / 5:45-9pm / $60 / $75 / $95
Option 8: Resection Symposium / 6-9pm / $40 / $50 / $60
Option 9: Hepatitis Symposium / 6-9pm / $40 / $50 / $60
Option 10: GI Motility Symposium / 6-8:30pm / $40 / $50 / $60

STEP 4: SPECIAL DIETARY NEEDS

Do you require a Kosherlunch on Thursday?_____ Yes_____ No
Do you require a Kosherlunch on Friday? _____ Yes_____ No
Please list any other special dietary needs: ______

STEP 5: PAYMENT INFORMATION

_____ CHECK ENCLOSED**Check Number: _____Total Payment Amount: ______

_____ CREDIT CARD_____ American Express_____ Master Card

_____ Visa_____ Discover

Credit Card No.______Expiration Date (mm/yy):______

CID (Security Code):______Name as Printed on Card: ______

Billing Zip Code: ______

Signature:______

STEP 6: SUBMISSION OPTIONS

Fax the entire 2-page registration form to: 866-381-7288

Email the entire 2-page registration form to

Mail check payment and entire 2-page registration form to:

NYSGE c/o DHW

3300 Woodcreek Drive

Downers Grove, IL 60515

**Please note: Forms and checks or credit card information must be RECEIVED by the last eligible date respective to the fee paid.

Name of person completing this form (if other than registrant): ______

Email ______Phone ______]

Cancellation Policy

Refund less $50 processing fee for Annual Course registration and for Options 1, 2, 3, 6, and 7, will be given when requested in writing and submitted no later than December 9, 2015. No refunds will be made after this date. A full refund for Options 4, 5, 8, 9, and 10 will be given when requested in writing and submitted no later than December 9, 2015. No refunds will be made after this date.