Meeting Registration Form ONLINE REGISTRATION www.aserhq.org Online registration accepted until Friday, April 14, 2017 MAIL OR FAX REGISTRATION FORM This is how your name will appear on your name badge. *Required fields. *FIRST NAME: *LAST NAME: PROFESSION: *COMPANY/INSTITUTIONAL AFFILIATION: *ADDRESS: *STATE/PROVINCE: *PHONE: *EMAIL ADDRESS: Special Needs: Hearing Impaired Sight Impaired Other: Dietary (Please Specify) REGISTRATION FEES Course materials, 1 cocktail events, 3 lunches & 3 continental breakfasts Early Bird by 2/17/17 ASER Physician Member Registration ...................................... $600.00 ASER Physician Non-Member Registration*............................. $725.00 ASER Non-Physician Member Registration ................................ $50.00 ASER Non-Physician Non-Member Registration ...................... $150.00 Residents/Fellows/Medical Students Registration ................... $50.00 ASER Industry Member .......................................................... $600.00 ASER Industry Non-Member*................................................. $725.00 *Non-member fee includes 1 year of membership. SUB TOTAL: PAYMENT MUST ACCOMPANY REGISTRATION TOTAL DUE: 3/31/17 $700.00 $825.00 $75.00 $175.00 $50.00 $700.00 $825.00 *HIGHEST DEGREE(S): Paper Registrations By Fax or Mail (SEE CONTACT INFORMATION BELOW) If you are unable to register online please fax or mail your paper registration form. Onsite Registrations Online registration accepted until April 14, 2017. After April 14th limited onsite registration is available. *ZIP: FAX: *COUNTRY: Registration Cancellation All cancellations must be in writing and sent via U.S. mail, email or fax. Fee for cancellations postmarked or date stamped before April 14, 2017 will be completely refunded with an administrative fee of $25. NO REFUNDS WILL BE MADE AFTER APRIL 14, 2017. After 4/14/17 $800.00 $925.00 $100.00 $200.00 $50.00 $800.00 $925.00 Questions? Contact Us: American Society for Enhanced Recovery 6737 W. Washington St. Suite 4210 Milwaukee, WI 53214 info@aserhq.org office: 414-389-8610 fax: 414-276-7704 PLEASE NOTE: Registration is not complete until you receive a confirmation email for your registration. If you do not receive this email within 5-7 days of registration, please contact us at 414-3898610. METHOD OF PAYMENT The following methods of payment are acceptable for the registration fee: 1. Check: Made payable to ASER. There is a $25 returned check fee. Check Included 2. Credit Card Payments: Visa MasterCard Discover AMEX NAME ON CARD: CARD #: SECURITY CODE: SIGNATURE: It is recommended to bring your confirmation of registration with you to the conference. EXP. DATE: /
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