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Workshop Registration Form
Full Name (First and Last):
 
Email Address:
Pacemaker Bank:
City:
Country:
Workshop Attendance:
I plan to attend the 2007 Workshop
I do not plan to attend the 2007 Workshop
Board of Directors Meeting:
 
I plan to attend
I do not plan to attend
Registration:
I have registered with the ACC for hotel only
I have registered with the ACC for hotel and sessions
Please identify one or two topics that would be important to you (related primarily to arrhythmia therapy).
Topic #1:
Topic #2:
Please identify one or two faculty members who could deliver these topics in a knowledgeable and engaging fashion. (provide topics even if you have no preference on faculty members)
Faculty Member #1:
Faculty Member #2:
Device Transportation:
I can transport devices back to my Bank
I cannot transport devices back to my Bank
Please select one of the below so that we can package up the appropriate devices and forward an invoice for pre-Customs clearance.
Number of Devices:
I can take 5 devices
I can take 10 devices
I can take 15 devices
I can take 20 devices
Package:
Include one ICD in my package
Include two Catheters in my package
BiV pacemaker
Will other Pacemaker Bank representatives be joining you at the workshop?
If so, list their names below and provide their email addresses:
Representative #1:
Representative #1 Email Address:
 
Representative #2:
Representative #2 Email Address:
 
Representative #3:
Representative #3 Email Address:
 
Representative #4:
Representative #4 Email Address:
 
Representative #5:
Representative #5 Email Address:
 
 
 

Heartbeat International
6800 N Dale Mabry Hwy #124 • Tampa, FL 33614-3998
Phone: (813) 243-8769 • Fax: (813) 496-1319

E-mail: info@heartbeatintl.org