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CUA BPH Hands-on-Training (HOT) Course
TWO SESSIONS AVAILABLE:
Sunday, June 28th from 16:45 - 18:30 (12 spots available)
DATES
Monday, June 29th from 7:00 - 8:45 with breakfast (12 spots available)
Please indicate date of attendance:
Identification
Name:
Address:
City:
Province:
Postal Code:
Tel.:
Fax:
Email:
Credit Card Payment
A $25 reservation fee is required upfront
I _______________________________ , authorize the Canadian Urological Association to charge my credit card.
For services rendered. Not to exceed the amount shown.
AMOUNT: ____________________($ CAD)
CREDIT CARD TYPE: _____________________________
EXPIRATION DATE: ___________________
CREDIT CARD NUMBER: _______________________________________________________________________
NAME (as it appears on card): __________________________________________________________________
SIGNATURE: ________________________________________
If you have any questions, please contact:
Raffaella Leroux
raffaella.leroux@cua.org
T: 514-395-0376 ext. 41 | F: 514-395-1664
www.cua.org
DATE: _____________________________
This course has been developed and accredited by the CUA with
logistical support from