Washington, DC | March 12-15, 2017
Learn more at www.acep.org/lac
REGISTER ONLINE
REGISTER BY PHONE
www.acep.org/lac
800-798-1822
REGISTER BY FAX
REGISTER BY MAIL
972-580-2816
ACEP Meeting Registration
PO Box 619911
Dallas, TX 75261-9911
(Available 24 hours)
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REGISTRATION FEES—HOTEL ROOM NOT INCLUDED
Regular Rate
Onsite Rate
□ACEP Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180 . . . . . . . . . . . . . . . . . . . . . . $250
□ACEP Resident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $60 . . . . . . . . . . . . . . . . . . . . . . $250
□Non-Member Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$500 . . . . . . . . . . . . . . . . . . . . . . $500
□SEMPA or AAENP Member . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $300 . . . . . . . . . . . . . . . . . . . . . . $300
□Leadership Day Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $180 . . . . . . . . . . . . . . . . . . . . . . $180
An RSVP is requested for the following functions. Please check all that apply.
□Monday, March 13, Luncheon
□Tuesday, March 14, Lunch
□Tuesday, March 14, Congressional Reception
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□Guest
□Guest Name_________________________________________________
CONTACT INFORMATION
NAME (Last, First, Middle)
ACEP ID NUMBER
TITLE (MD, DO, RN, NP, LVN, EMT, PAR A, PhD, RPh, PharmD, PA, FACEP)
NICKNAME FOR BADGE (If different)
MAILING ADDRESS
CIT Y/STATE /COUNTRY/ ZIP+4
PREFERRED TELEPHONE NUMBER (Including area code)
E-MAIL ADDRESS (Required for ACEP confirmation & evaluation correspondence only)
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EMERGENCY CONTACT (Please print or type)
NAME (Last, First, Middle)
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NATIONAL PROVIDER IDENTIFIER (NPI)
TELEPHONE NUMBER
REL ATIONSHIP
PAYMENT METHOD (Payment is due at time of registration)
□Please charge my credit card: □VISA
□MasterCard
□Discover
□My check for $____________ is enclosed (Payable to ACEP in US currency only)
□American Express
NAME AS IT APPE ARS ON CARD ( Please Print)
CARD NUMBER
E XPIR ATION DATE
SECURIT Y CODE
ZIP CODE OF BILLING ADDRESS
SIGNATURE
CANCELLATION POLICY Cancellations must be submitted in writing. No telephone cancellations will be accepted. A $75 cancellation fee will be assessed.
No refunds will be made for cancellation requests postmarked after Saturday, March 11. To cancel, write to ACEP Meeting Registrar, PO BOX 619911, Dallas,
TX 75261-9911, fax to 972-580-2816, or email [email protected].
QUESTIONS OR INFORMATION E-MAIL: [email protected]