TEMPORAL BONE SURGICAL DISSECTION COURSE
APPLICATION FORM
Contact Information

First Name:

Middle Initial:

Last Name:

Age:

Mailing Address: 

Address 2 (Street):

Address 3 (City/State):

Address 4 (Country/Zip Code):

Home Phone:

Business Phone:

Fax:

E-Mail:

Professional Education

Medical School Attended

Year

Residency Program

Year Residency completed

Residency/Fellowship-1

Year

Residency/Fellowship-2

Year

Residency/Fellowship-3

Year

Residency/Fellowship-4

Year

Special Training in Otology

Teaching Appointments

Course Dates (select one)
2011

October 16 - 19, 2011

February 5-8, 2012

March 25-28, 2012

June 10-13, 2012

October 14-17, 2012
Surgical Dissection Instruments
Please specify if you are:
Right Handed
Left Handed
Do you require Set A Instruments?
(Please refer to the List of Required Equipment--Set A)
Yes Please reserve for me in advance Set A Instruments (There is a fully refundable $150.00 deposit for Set A Instruments to be added to tuition payment).
No I have a complete set of instruments which I will bring with me
Do you require Set B Instruments? Stapedectomy Set:
(Please refer to the List of Required Equipment--Set B)
Yes Please reserve for me in advance Set B Instruments  (There is a fully refundable $100.00 deposit and in addition, a $100.00 rental fee for Set B Instruments to be added to tuition payment).
No I have a complete set of instruments which I will bring with me
Tuition: (Payment in full is due 90 days before the course.) 

Practitioner- $1,600.00    plus instrument fees

Resident- $1,400.00   plus instrument fees

**All Residents must provide a certification letter from their Chief of Service by email attachment.
Method of payment:
Credit card

Payment by Visa, American Express or MasterCard should be made by calling Karen Hall at the House Ear Institute, Finance Office
at (213) 483-4431 ext. 7009.

Check

Payment by check should be made payable to House Ear Institute and mail to:

Department of Education,
House Ear Institute,
2100 West Third Street,  5th Floor,
Los Angeles, CA 90057.