Delegate Registration



First Name: Last Name:
Degrees: M.D. D.O. D.P.M. D.D.S. D.M.D. Other Other degree(s):
Hospital:
Department: PGY:
Home Street Address:
City: State: ZIP Code:


Mobile Phone:

Email:


ROOM RESERVATION If you share a room with another delegate, CIR will pay the full cost of the room ($240.80 per night double occupancy) at the Hyatt Regency Philadelphia at Penn's Landing. If you wish your own room, you will be charged half the cost of a room ($120.40/per night).
Roommate preference:	I want my own room, and understand that I will pay $120.40 per night. Please choose a roommate for me -- I am afemale male I will share a double room with Dr. -- I have his/her approval.
(You must provide a current credit card when you arrive at the hotel. Any incidental expenses you incur during the convention (phone calls, room service) will be charged to your credit card. If you cancel 72 hours before your scheduled arrival date, you will not be responsible for any charges.)
Dietary restrictions:	None I do not eat meat I do not eat meat or fish Other If other, please specify:
TRAVEL, ARRIVAL AND DEPARTURE INFORMATION Please make your plane or train reservations with UN Travel: Call (800) 234-8685 and indicate that you are attending the CIR convention. PLEASE NOTE that the CIR 2009 National Convention begins on Friday, May 15 at 6:30 pm with registration and reception at the Hyatt Regency Philadelphia at Penn's Landing. I will arrive in Philadelphia, PA, on:
	Friday, May 15th at ampm
	or Saturday, May 16th at ampm (The Convention begins at 8:30 am sharp!)
I will travel by:	plane train car other
I will leave Philadelphia, PA, on:
	Saturday, May 16th at ampm
	or Sunday, May 17th at ampm

ROOM RESERVATION

TRAVEL, ARRIVAL AND DEPARTURE INFORMATION