APS 34th Annual Scientific Meeting Registration For 34th Annual Scientific Meeting Registration Form…

Download APS 34th Annual Scientific Meeting Registration For 34th Annual Scientific Meeting Registration Form…

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    APS 34th Annual Scientific Meeting Registration Form May 1316, 2015 Palm Springs Convention Center Palm Springs, CA

    FOR OFFICE USE ONLY

    Customer #_________________ Mtg Ord # 1-________________

    Date_____________________ I __________________________Please type or print clearly. Use a separate form for each registrant; duplicate as necessary.

    Full Name _______________________________________________ First Name for Badge __________________________________ Highest Credential _____________________

    Facility ___________________________________________________________________________________ Facility City/State _________________________________________

    Preferred Address (q Home q Office) ______________________________________________________________________ City/State/ZIP _________________________________

    Home Phone __________________________________________ Office Phone __________________________________ Fax ___________________________________________

    E-mail (required) ___________________________________________________________________________________________________________________________________

    Emergency Contact Name _________________________________________________________ Day Phone ____________________ Evening Phone _______________________

    (BCR) q Check here if you do basic/preclinical research. (FTA) q Check here if this will be your first APS Annual Meeting. NPI # _________________________

    GFull Meeting RegistrationAPS Member On or Before After To join APS, add dues in box C. 4/13/15 4/13/15

    Income > $100,000 q $595 q $695 < $100,000 q $320 q $420Student/Trainee q $100 q $180

    NonmemberIncome > $100,000 q $700 q $800 < $100,000 q $465 q $565

    Subtotal $ ______________

    F Basic Science(select area of expertise)

    n Neurophysiology (BSN)n Behavioral (BSB)n Systems (BSS)n Other (BSO) Specify below.

    ________________n Behavioral Science (BSC)n Biomedical Engineering (BE)n Business/Industry (BUS)

    n Chiropractic (CHI)n Dentistry (DEN)n Health Policy (HP)n Nursing (NSG) n Occupational Therapy (OT)n Pharmacy (PHA)n Physical Therapy (PT)Physician (select area of expertise)

    n Anesthesiology (ANS)n Emergency Medicine (EM)

    n Family Practice (FP)n Gynecology (GYN)n Internal Medicine (IM)n Neurology (NEU) n Neurosurgery (NS)n Oncology (ON)n Oral/Facial Surgery (OS)n Orthopedic Surgery (ORS)n Pediatrics (PED)

    n Physical Medicine &

    Rehabilitation (PMR) n Psychiatry (PSY) n Rheumatology (RHE) n Surgery (SUR) n Urology (URO)

    n Psychology (PSI)n Social Work (SW) n Other (OTH) Specify below._____________________________

    Primary Specialty (Required; please select one.)

    1-Day Meeting Registration (for registrants attending only 1 day of the meeting)

    Please select which day you will be attending. Be sure to complete boxes G & H for the appropriate day.

    q Thursday (TH) q Friday (FR) q Saturday (SAT)

    APS Member (1-Day Rate)

    Income > $100,000 q $360 < $100,000 q $280

    Nonmember (1-Day Rate)

    Income > $100,000 q $425 < $100,000 q $375

    Subtotal $ ______________

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    B Symposia Enter the 3-digit code for each symposium you plan to attend. Visit www.americanpainsociety.org/annualmeeting for codes.

    Thursday, May 1411 am12:30 pm 2:153:45 pm Friday, May 1510:30 amNoon 1:453:15 pm 1:455 pm 3:305 pm Saturday, May 161011:30 am

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    Special EventsCheck the box and enter the 3-digit code for each event you plan to attend. Visit www.americanpainsociety.org/annualmeeting for codes. Wednesday, May 1314:15 pm q (118) Early Career ForumThursday, May 145:156:15 pm q SIG Meeting

    Friday, May 155:157:15 pm q SIG Meeting 5:307:30 pm q (136) Basic Science Research Dinner Advance registration required.

    Saturday, May 1611:45 am1 pm q (900) National Pain Strategy Presentation

    If payment does not accompany this form, your registration will not be processed.

    MasterCard Visa American Express Discover Check (enclosed)Payment

    Make check payable to APS. A charge of $75 will apply to checks returned for insufficient funds.

    If rebilling of a credit card charge is necessary, a $75 processing fee will be charged. I authorize APS to charge the above listed credit card amounts reasonably deemed by APS to be accurate and appropriate.

    Account Number Expiration Date

    Cardholders Name (Please print.) Signature

    4 easy ways to registerOnline (preferred method)www.americanpainsociety.org/annualmeeting(credit card payment only)

    Phone847.375.4715(credit card payment only)

    Fax* 866.574.2654 or 847.375.6479International Fax 732.460.7318(credit card payment only)* If you fax this form, please do not mail the original.

    MailAPS Meeting8735 W. Higgins Road, Suite 300Chicago, IL 60631

    Photography Disclosure: Photographs and/or video may be taken of participants at APSs 2015 Annual Meeting. These photos are for APS use only and may appear on APSs website, in printed brochures, or in other promotional materials. Attendee registration grants APS permission and consent for use of this photography.

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    Guest RegistrationIncludes access to all general sessions, exhibit hall, and networking events. No continuing education credits are offered with a guest pass.

    Guest Name(s) __________________________________

    ______________________________________________

    Number of Guests (GST) ________ x $75

    Subtotal $ ______________

    Grand TotalBe sure to complete boxes F, G, H, & I.

    (A or B) + C + D + E = $__________________

    Special Needs(SA) q I require special assistance. Please contact me.(DIS) q I do not wish to have my name and contact information

    included in the onsite attendee list.(OTH) q I have other needs. Please contact me. (SDV) q Vegetarian meal request

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    CJoin APS (Membership Rates)Regular

    Income < $75,000 q $120 $75,000 to $124,000 q $190 $125,000 to $174,000 q $275 > $175,000 q $325International q $150Undergraduate q $50Graduate/Professional Student q $50Postdoctoral/Resident/Fellow q $90

    Subtotal $ ______________

    DSpring Pain RegistrationMay 1113

    Spring Pain Only q $150

    With Full Annual Meeting Registration q $100

    Subtotal $ ______________

    To register, make your selections in the boxes below, add the subtotals, and indicate the total amount in box J.