International Equine Podiatry Center
18th Bluegrass Laminitis Symposium Registration Form

Please type in all information below and fax/mail to IEPC. Name: Address: City:  State:   Zip:  Country: Email: Phone:  Fax: Check one of the following: DVM Farrier Owner   Farm Manager  Student  Other NOTE: If registering more than one person, please submit information on separate sheets. Description Price Total 3 Day Lecture Fee (Postmarked on or before Dec, 4 2006) $350.00 $ 3 Day Lecture Fee (Postmarked after Dec 4, 2006) $450.00 $ Student Rate 3 Day Lecture Fee (ID required on school letterhead) $250.00 $ 1 Day Lecture Fee, Check day attending: Jan 26 27 28 $250.00 $ Special Radiographic Session: Jan 26 6:30-8 p.m. $125.00 $ NOTE: POSTMARK STRICTLY ENFORCED!                                   TOTAL AMOUNT $ PAYMENT TYPE:  Must be in US Funds   Credit Card   Check**   Money Order ** Make checks payable to International Equine Podiatry Center, Inc. CREDIT CARD PAYMENT INFORMATION: TYPE OF CARD:   Visa   MasterCard   American Express   Discover   Diner's Card CARD NUMBER: **Please Include 3 digit code on back for Visa, MC, & Discover or 4 digits on the front for AMEX** EXP. DATE CARDHOLDER'S NAME AS IT APPEARS ON THE CARD: CARDHOLDER'S SIGNATURE: X  Fax form to: (502) 839-6766 Phone: (877) 462-6742 Email: IEPC@nanric.com Mail form to: International Equine Podiatry Center, Inc. 209 E Woodford St Lawrenceburg, KY 40342