February 2, through February 27, 2009

Location: UT Medical School at Houston
Tuition: $1,800 (full payment must be received by 02/02/09)
Make checks payable to HERMANN EYE FUND
Application deadline: December, 31, 2008

REGISTRATION FORM

Name___________________________________ MD/DO/PhD

Address______________________________________________

City_________________________ State______ Zip__________

Telephone____________________ Fax____________________

E-mail address________________________________________

PGY Level ______

Residency Program ___________________________________

Chairman_____________________________________________

Address_______________________________________________

City_________________________ State______ Zip___________