2010 Annual Meeting Registration

PERSONAL INFORMATION:
First Name:
Last Name:
Designation:	Other:
Institution:
Street Address:
City:
State:
Zip:
Country: (if not U.S.A.)
Telephone:
Fax:
E-Mail:

NAME BADGE INFORMATION:
Name on name badge:	(e.g., Jane A. Doe, M.D. or Mr. John Smith)	What's this?
City, State or Country on name badge:	(e.g., Atlanta, GA or Toronto, Canada)	What's this?
Attendant's First Name:	(if applicable)
Attendant's Last Name:	(if applicable)
Guest's First Name:	(if applicable)
Guest's Last Name:	(if applicable)
Please check if applicable: Speaker Poster Presenter Moderator
Check here for special needs: Accessibility Dietary

PRE-COURSE SELECTION:
PRICING INFORMATION	Early by 3/1/10	Regular after 3/1/10	On-Site after 5/4/10
INSTeP	$175.00	$225.00	$275.00
I am exempt from paying for the Pre-Course

REGISTRATION SELECTION:
PRICING INFORMATION	Early by 3/1/10	Regular after 3/1/10	On-Site after 5/4/10
Member	$375.00	$425.00	$475.00
Non-Member	$475.00	$525.00	$575.00
Student, Fellow, Resident (with written verification from department chair)	$150.00	$200.00	$250.00
Single Day Admission (Member)	N/A	$250	N/A
Single Day Admission (Non-Member)	N/A	$300	N/A
Single Day Admission (Student, Fellow, Resident)	N/A	$100	N/A
Exempt From Registration Fee	$0.00	$0.00	$0.00
I Will Not Be Attending the Conference	$0.00	$0.00	$0.00
I have already registered for the meeting, but wish to purchase some extras	$0.00	$0.00	$0.00

Add your extras:
Presidential Reception/Gala (Member) what's this?	$35	$35	$35
Presidential Reception/Gala (Extra Ticket) what's this?	$75	$75	$75
Attendant (includes all food and beverage & Welcome Reception)	$100.00	$100.00	$100.00
Guest (Welcome Reception only)	$50.00	$50.00	$50.00
Innovation Fund	$25.00	$50.00	$75.00

Discount Code:		How do I get a discount code?

Pay by:

Credit Card
Check
Exempt

I am registering/paying for someone else.

Your Name:

Please be sure to review the above information for accuracy BEFORE clicking Submit.

Refund and Cancellation Policy:
Registration cancellations WILL NOT be accepted by phone.
Cancellations MUST be in writing.

A $75 fee will be assessed and the balance refunded for cancellations postmarked through March 15, 2010.
NO REQUESTS FOR REFUNDS WILL BE ACCEPTED AFTER MARCH 15, 2010.
Refunds will not be issued until after the meeting.
Partial or full fees that have been forfeited cannot be applied to subsequent years.