PRE-REGISTRATION FORM
The
2010 Annual Meeting of
The American Academy of Cardiovascular Perfusion
|
MEMBER |
FEE |
Amount |
FIRESIDE CHAT REGISTRATION Thursday Sessions 1)____________________________ Friday Sessions 1)____________________________ 2)____________________________ 3)____________________________
2)____________________________ |
| NON-MEMBER Registration Fee Adult Guest to Workshop |
FEE |
Amount |
|
| STUDENT PERFUSIONIST Registration Fee Adult Guest to Workshop *MUST include a letter from the school director with registration. To take advantage of the Student rate of $30.00, you must be a current Student Member of The Academy. |
FEE |
Amount |
|
| FELLOW or SENIOR MEMBER Registration Fee 2010 Annual Dues Guest to Formal Dinner Adult Guest to Workshop |
FEE |
Amount |
|
PRINT OR TYPE NAME ________________________________________________________________ ADDRESS _____________________________________________________________ CITY _________________________________ STATE _______ ZIP _________________ HOME PHONE __________________ WORK PHONE __________________ FAX ____________________ E-MAIL ADDRESS ____________________________________________ (Required for confirmation) ANTICIPATED ARRIVAL DATE IN NASHVILLE _______________________ |
|
Please Read all Instructions and Information before completing this form. If you have questions completing this form, please call the national office. Hotel Reservations must be made separately through the hotel directly. Total Amount of Payment $ ________ METHOD OF PAYMENT: Check** __ Money Order __ Credit Card VISA/MasterCard # _______________________________ Exp. Date ________ 3-digit security code _ _ _ Credit card billing address if different from above. ADDRESS _____________________________________________________________ CITY _________________________________ STATE _______ ZIP _________________ Signature_____________________________________ ** There will be a $25.00 service charge for any check returned for insufficient funds. |
INSTRUCTIONS and INFORMATION
o Complete each appropriate section of this form by printing or typing.
o Members must pay their 2010 Annual Dues along with their registration fees by completing that portion of the form.
o You will receive acknowledgment of your pre-registration by January 15, 2010—bring it with you to the meeting.
o No pre-registration will be processed after December 29, 2009.
— After this date you must register at the meeting.
o Your receipt and meeting credentials will be available for you at the Pre-Registration desk at the meeting.
o There will be NO ADMISSION to any Fireside Chat without proper admission credentials.
o If you are joining The Academy with your registration you must:
1) complete appropriate areas of the form;
2) you MUST INCLUDE the membership application form;
3) include the $25 filing fee;
4) include $145 for the 2010 Annual Dues;
(Your membership begins with the closing business meeting)
o ONLY VISA/MasterCard credit cards are accepted - with VISA/MasterCard you may FAX your registration
to (717) 867-1485
o The AACP Federal Tax ID Number: 63-0776991 (for hospital use only)
o Refund policy: Anyone that is pre-registered for this meeting and is unable to attend will receive a full refund minus
$50.00 for handling, mailing, and processing upon written request before January 12, 2010.
o Make checks payable to AACP (US dollars). Mail completed pre-registration form and check to:
AACP
515A East Main Street
Annville, PA 17003
IF YOU HAVE QUESTIONS FILLING OUT THIS FORM, PLEASE CONTACT THE NATIONAL OFFICE (717) 867-1485.
o If paying by VISA/MasterCard you may FAX this form to (717) 867-1485 or mail to above address.
