The New York Society for Gastrointestinal Endoscopy
Cordially Invites You to Attend Our
ANNUAL DINNER BUSINESS MEETING
and
PAUL SHERLOCK DISTINGUISHED LECTURE
Personal Journey in Anecdotes
Presented by
Jean W. Saleh, MD, NYSGEF
Professor of Medicine
Icahn School of Medicine at Mount Sinai
Mount Sinai St. Luke’s and Mount Sinai Roosevelt
Wednesday, February 3, 2016
7:00 pm – 10:00 pm
Three Sixty°
10 Desbrosses Street
New York, NewYork 10013

HOW TO ORDER TICKETS

ONLINE (Preferred Method)

  • Visit
  • Login with your user name and password (contact us r call 646-218-0650 for assistance)
  • Click on Annual Dinner Meeting and Paul Sherlock Distinguished Lecture under Upcoming Events.
  • Click on the green REGISTRATION button to register yourself and any guest(s).

MAIL-IN OR FAX

STEP 1: PLEASE TYPE OR PRINT ALL INFORMATION

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

STEP 2: SPECIAL DIETARY NEEDS

  1. Do you require a Kosher meal?_____ Yes_____ No
  2. Do you require a Vegetarian meal? _____ Yes_____ No
  3. Please list any other special dietary needs:

STEP 3: Reservation

Number of Tickets / Ticket Type / Ticket Price
NYSGE Member Physician / $175
Guest of Member or Fellow / $175
GI Fellow / $135
Non-Member Physician / $200

Name of Guests Using Above Tickets (Indicate Special Dietary Needs Next to Guest Names):

______

______

______

______

Name of Institution to Be Seated with (optional): ______

Name of Individuals to Be Seated with (optional): ______

STEP 4: PAYMENT INFORMATION

_____ CHECK ENCLOSEDCheck 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 5: SUBMISSION OPTIONS (MUST BE RECEIVED BY JANUARY 27, 2016)

  1. Fax the entire 2-page registration form to: 866-381-7288
  2. Email the entire 2-page registration form to
  3. Mail check payment and entire 2-page registration form to:

NYSGE/DHW

3300 Woodcreek Drive

Downers Grove, IL 60515

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

Email ______Phone ______

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