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. Internet