ADVANCE

REGISTRATION

Primary Specialty Please select one from the list below.

� Endocrinology � Cell Biology � Molecular Biology

� Orthopaedics � Metabolism � Rheumatology

� Internal Med. � Epidemiology � Pharmacology

� Molec. Genetics � Physiology � Biomechanics

� Nephrology � Dentistry � Developmental Biology

� Pathology � Ob-Gyn � Oncology

� Other

ASBMR 2012 Annual Meeting | October 12-15, 2012

Minneapolis Convention Center | Minneapolis, MN, USA

Early Registration Deadline: Thursday, August 16, 2012

Badge & Mailing Information Please clearly PRINT as it should appear on badge.

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First Name Last Name/ Surname

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Institution

____________________________________________________________________________

Address

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City State/Province Zip/Postal Code

____________________________________________________________________________

Country Telephone

____________________________________________________________________________

Email Address

� M.D. � Ph.D. � M.D., Ph.D. � Other ____________________________________

� First-Time Attendee

NPI Number _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

Pharmaceutical/medical device exhibitors are required by the 2010 Federal Patient Protection

and Affordable Care Act to disclose to the Department of Health & Human Services any

"payment or other transfer of value" given to a physician. The National Provider Identifier

(NPI) number is required as part of this disclosure. This information will be shared with

exhibiting companies that scan your badge at their booth

Special Needs

� We want to ensure that you enjoy ASBMR’s 2012 Annual Meeting. If, due to a disability,

you have any special needs, please let us know and we will do our best to assist you.

____________________________________________________________________________

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Research Type Please select one from the list below.

� Basic � Clinical � Translational � None

Cancellation Policy Refunds will be issued if request is received in writing by Thursday, August

16, 2012. Spouse/Guest, Working Group fees and social event tickets are non-refundable. All

refunds will be processed after the Annual Meeting and will be assessed a $100 administrative

fee. Only current members at the time of registration are eligible for the discounted member

registration rates. ASBMR does not refund the difference in registration fees paid by

individuals who register as non-members but apply/are accepted as a member of the Society

following their registration as a non-member. All sales are final after August 16, 2012. Email

requests to: asbmr@showcare.com

Submitting Registration � Mail �Fax �Questions

ASBMR Registration (905) 479-9297 (202) 367-1173

Department 3108 asbmr@showcare.com

Washington, DC 20042-3108

Hel p A SBMR co n s erv e by r eg i st er in g o n l i ne at www . asb mr. org

2012 Meeting Fees Please check appropriate box.

On or before On or after

Registration Fees Aug 16 Aug 17

Member ID# ____________ � $340 � $465

Non-Member � $630 � $755

Resident/Student/Fellow Member* ID# ____________ � $205 � $255

Resident/Student/Fellow Non-Member* � $295 � $345

Allied Health Professional* � $295 � $345

Spouse/Guest Name ___________________________ � $40 � $50

Includes Welcome Reception

Subtotal _______________________

Optional Events and Products

Social Event Saturday, October 13 � $30

Meet the Professor Handout Booklet � $10

Speed Networking Event Friday, October 12 � $35($15 students)

Abstract Book printed and bound, for pick up onsite � $25

Continuing Medical Education Credits (CME) � $50

Help ASBMR support Young Investigators � $__________

Help us support education, research and bone and mineral science by making a donation.

Subtotal _______________________

Working Group Fees

Friday, October 12

Working Group on Skeletal Aging � $40

Working Group on Pharmacoepidemiology � $10

Nutrition Working Group � $25

Muscle and Bone Working Group � $30

CKD-MBD Working Group � $20

Adult Bone and Mineral Working Group � $30

Sunday, October 14

Bone Strength Working Group � $25

Rare Bone Disease Patient Network Working Group � $25

Rheumatic Diseases and Bone Working Group � $50

Pediatric Bone and Mineral Working Group � $35

Working Group on Musculoskeletal Rehabilitation � $25

Bone Turnover Marker Working Group � $30

Subtotal _______________________

Grand Total _______________________

Special Opportunities Open to residents, students, fellows, new members & minorities

Friday, October 12

New Investigator/Member Reception � YES

Saturday, October 13

ASBMR Networking Breakfast � YES

*Certification for Residents, Students, Fellows and Allied Health Professionals

I, __________________________________________________ ,(name of training mentor)

certify that the individual registered above is a Resident/Student/Fellow/Allied Health

Professional (circle one) at my institution/company.

Signature____________________________________________________________________ Payment Information Payment must accompany this form for processing.

� Check Enclosed Drawn on US Bank and made payable to ASBMR

� Credit Card � Visa �MasterCard �AmEx

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Card Number Exp. Date

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Name on Card

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Signature

Content Re-Use Policy ASBMR Annual Meeting participants must abide by the Society’s

policy on re-use of meeting materials, which may be found on the ASBMR web site.