PURCHASE FORM FOR PROCEEDINGS BOOKLET    
ISVD SATURDAY PM SESSION AT ECVP/ESVP 2009
SEPTEMBER 12, KRAKOW	
PERSONAL Information	
Name and Degree:     	
Hosp/Company/Institutional Affiliation:     	
Street address:     	
City:     	State:     	Country:     	
Telephone:     	Email Address:     	
Fees	
Non-members $25 	
Full ISVD* members $15	
Residents (ISVD* or non-ISVD) $10	
[*Please keep in mind that all ISVD members have access to a full-color pdf version of the
Proceedings included in their membership dues.  The printed version has B&W images.]	
Payment details	
 I have enclosed a check or money order in the amount in US dollars or the equivalent. Checks for US dollars must be drawn on a US bank.	
am paying by:	  VISA 	  Mastercard	Signature:	
Card Number:          -              -              -                	Exp date      /     (MM/YY)	
Security code (the 3 digits on the back of the card)         	
Billing address (if different from above):     	
Street address:     	
City:     	Country:     	Postal / ZIP Code:     	

Please mail your completed form to:

ISVD
C/O Emily J Walder, VMD
623 Woodlawn Ave
Venice, CA 90291 USA

If paying by credit card, you can also fax the form to (00-1-) 310-574-3330.
For security reasons, please do not e-mail credit card info.