Jules Stein Eye Institute

Jules Stein Eye Inst= itute

UCLA Department of Ophthalmology Association

Registration Form, 2008- = 2009

If you would like to = support the important activities of the JSEI Alumni Association, please return this form with your check payable to the UCLA Department of Ophthalmology Association at the address is listed below. Your attendance is very important to us, so please be= sure to attend all alumni activitie= s, regardless of dues payment. <= o:p>

If you will be attend= ing the upcoming reception at the annual AAO Meeting, please fill out and fax this = form back to us at 310-794-7781 or include it with your payment.

__ Yes! I would like to support the Alumni Association and its many important activities. =

I understand this support is optional. My check for $80.00 in annual membership dues is enclosed.

&nb= sp; Check this box only if you D= O NOT want your name listed on a roll call of dues paying members.=

__ Yes! I plan to attend= the annual UCLA Department of Ophthalmology Association Reception at the Ritz Car= lton, Atlanta Hotel, S= unday, November 9, 2008 in Atlanta, Georgia.<= span style=3D'mso-spacerun:yes'> = ;

&= nbsp;

__ I will be bringing a guest. <= /o:p>

Name(s) of guest: __________________________________________________=

__ Sorry, I am unable to attend the annual reception this year.

Name: = ___________________________________= ___________________________________________

Mailing Address: _________________________________________= _____________________________________

(Indicate Home or Business)

Phone Number:     _________________= _____________________________________________________________

(Indicate Home or Business)

E-Mail Address:   _____________________________= _________________________________________________

Did you complete your= residency at JSEI? &n= bsp;   __ Yes   __ No

What year(s) did you = attend?         &= nbsp;           &nbs= p;      First Year: ______________     Last Year: _____= __________

Did you complete a fellowship at JSEI?           __ Yes   __ No

What year(s) did you = attend?         &= nbsp;           &nbs= p;      First Year: ______________     Last Year: _____= __________

Please indicate your = practice specialty ______________________________________________________________

Return this Form to:

UCLA Department of Ophthalmology Association

Jules Stein Eye Insti= tute

100 Stein Plaza, UCLA= , Room 1-124, Los Angeles,= California 90095-7000<= /st1:PostalCode>

Phone: 310-825-4148, Fax: 310-794-7781

E-Mail Address:   a= lumni@jsei.ucla.edu