On Line Registration
*Last FOUR digits of Social Security Number:
PREFIX:
Mr.
Mrs.
Ms.
Other, please indicate:
this is how your name will appear on you name badge.
*FIRST NAME:
*LAST NAME:
SUFFIX(JR.,SR., ETC.):
*COMPANY/INSTITUTIONAL AFFILIATION:
*SPECIALTY:
*DEGREE:
MD
DO
RESIDENT
Other:
*ADDRESS:
*CITY:
*STATE:
*ZIP:
*WORK PHONE:
*FAX:
*EMAIL ADDRESS:
*Required for CME credits
How did you hear about this conference?
Direct Mail
Email
Advertisement
Word of Mouth
Special Needs:
Hearing Impaired
Sight Impaired
Other:
Registration Fees
Physicians
$400
Physicians in Training
$200
Other Healthcare Providers
$200
Industry Professionals
**With let from program director.
$200
Payment must accompany registration.
TOTAL DUE:
Method of Payment
The following methods of payment are acceptable for the registration fee:
1.
Checks:
Make payable to Conference Management Solutions, LLC
Employer Check Included
Personal Check Included
Employer or Personal Check to Arrive Under Separate Cover
Please mail this printed page along with your check to:
Conference Management Solutions, LLC
Suite 200 2770 South Park Road Bethel Park, PA 15102
2.
Credit Card Payments:
Please note:
Registration is not complete until you receive the confirmation letter / email for your pre-registration. If you do not receive this letter within 5-7 days of registration, please contact us at 412.595.7676 ext. 203. It is recommended to bring your confirmation of registration with you to the conference.
