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2015 FOMA Mid-Year Seminar Registration Form (print and fax)

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2015
FOMA Mid-Year Seminar
September 17-20, 2015
Grand Hyatt Tampa Bay  Tampa, Florida
Approximately 25 1-A CME’s will be offered
including the mandatory hours for relicensure:
1 hour each of Professional & Medical Ethics  Florida Laws & Rules  Prescribing
Controlled Substances  and 2 hours of Prevention of Medical Errors and Domestic Violence
Pre-Registration Form
Name (please print)
FOMA Member
yes / no AOA #
Florida License #
Mailing Address
CityStateZip
Phone Signature (for CMEs)
Specialty/Certification
FaxE-mail
Name of Spouse or Guest (if registering)
Please Choose Appropriate Category Below
# of individual registrations
Member Rate BEFORE 8/24 Member Rate
AFTER 8/24
Non-Member
Practicing DO................................................................................
$425
$450
$600
FOMA Life or Retired DO.............................................................
$250
$275
$325
Nurse/Physician Assistant...............................................................
$250
$275
$325
Resident..........................................................................................
$100
$100
$125
Intern..............................................................................................
No fee
No fee
No fee
Student............................................................................................
No fee
No fee
No fee
TOTAL for all registrations: $ $
$
Method of payment (circle) Check/ Visa/ MasterCard/ American Express/ Discover
Card Number
Credit Card Billing Address: same as mailing address above or
City State For Hotel Reservations, contact the Hotel directly by
August 28, 2015 to receive room rate listed below:
Grand Hyatt Tampa Bay
2900 Bayport Drive, Tampa, Florida 33607
1-888-421-1442 or 1-813-874-1234
$167 single & double
Book Online at: http://www.foma.org/seminar.htm
Expiration Date V-Code
Billing Address:
ZipcodePhone
Please make your check payable to the FOMA
Mail your registration to the FOMA at
2544 Blairstone Pines Dr.  Tallahassee, FL 32301
Or fax this form to the FOMA at (850) 942-7538.
If you have any questions, call (800) 226-3662.
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