SHOE FITTER SEMINAR

Provided By CFS Allied Health Education

Sponsored By ORTHOFEET, Inc.

 REGISTRATION FORM

 First Name: ___________________________________________

 Last Name: ___________________________________________

 Company: ____________________________________________

 Address 1: ____________________________________________

 Address 2: ____________________________________________

 City / State / Zip:_______________________________________

 Phone #: _____________________________________________

 Fax #: _______________________________________________

 E-mail: _______________________________________________

 Seminar Location: _______________ Seminar Date: ____________

 __ Check Enclosed; Check #: _______ Check Amount ($)_________

 Credit Card:  ___Visa;  ___MasterCard;  ___American Express

 Credit Card #: _________________________________________

 Expiration Date: _____________

 Signature: _________________

 Please print out this form, fill out the information, and fax it to
 Orthofeet, Inc. at: 201-767-6748.

 If you are paying by check please mail it along with the form to:
 Orthofeet, Inc. 152 Veterans Drive, Northvale, NJ 07647
 

Orthofeet customers only
To order online,
please click here