2018 Annual
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FOMA CONVENTION
The Florida Mandatory
CME Hours will be Offered
1 hour of: Florida Laws & Rules  Professional & Medical Ethics 
State & Federal Laws Related to the Prescribing of
Controlled Substances and 2 hours of:
Prevention of Medical Errors
Earn Mandatory Hours for
February 21-25, 2018
Bonaventure Resort & Spa
Weston, FL
FLORIDA RELICENSURE !
Earn up to 35 1-A CMEs
Registration Form
Name (please print)_____________________________________________________________________________________________________
FOMA Member:
yes
/
no
AOA #_________________
Florida License # _______________________
Mailing Address___________________________________________________________________________________
City_________________________________
State __________________
Zip _____________________
E - m a i l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Fa x _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Specialty
Phone____________________
_______________________________ AOA Certification __________________________________
Osteopathic College ______________________________________________________________________ Year Graduated _________
Dietary Needs/Special Health ___________________________ Spouse or Guest (if registering)_________________________________
Please Choose Appropriate Category Below
# of individual registrations Member Rate Member Rate
BEFORE 1/20/18
After 1/20/18
____ Practicing DO����������������������������������������������������������������������� $525 $550
____ FOMA Life, Honorary Life Member, Military, Retired DO �������������� $300 $325
____ Attending DO’s Spouse or Guest.......................................���������� $125 $150
____ Nurse, Physician Assistant, Other Health Professional ���������������� $300 $325
____ Osteopathic Resident ____ Osteopathic Intern������������������������ $ 75 $ 75
____ Osteopathic Student ����������������������������������������������������������� No Fee No Fee
____ Sunday Only - 5 Florida Mandatory Hours....................................... $300 $300
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 Please make checks payable to the
FOMA and mail to the:
Florida Osteopathic Medical Assoc.
2544 Blairstone Pines Drive, Tallahassee, FL 32301
Or fax form to the FOMA at (850) 942-7538
$________
Non-Member
$750
$425
$175
$375
$150
No Fee
$550
$________
Signature
Expiration Date V-Code
Billing Address:
Zipcode Phone
For reservations, contact the hotel by January 30:
Bonaventure Resort & Spa
250 Racquet Club Road
Weston, FL 33326
1-954-389-3300
$255 single/double
1-800-327-8090
Questions? Call the Florida Osteopathic Medical Association at 1-800-226-3662
OFC