2015 AC Exhibitor Reg Form
2017 SVU Annual Meeting REGISTRATION FORM Save money! Register by July 3, 2017. Complete and submit a registration form (or a photocopy of it) for each participant. All SVU 2017 Annual Conference registrations must be prepaid by credit card, or a check (drawn on a U.S. bank, net of all bank charges).
Registrant information
Mr.
Mrs.
Ms.
Work:
Dr.
Address ______________________________________________
Name ________________________________________________________
City / State / Zip ________________________________________
Degree(s) / Credentials __________________________________________
Phone _________________________ Fax __________________
Job Title ______________________________________________________
Home: Address ______________________________________________ City / State / Zip ________________________________________
Institution ____________________________________________________ E-mail
Phone _________________________ Fax __________________
______________________________________________________
Special needs due to disability or special meal request:
YES
Preferred Mailing Address:
NO
Fees are listed: Early Rate on or before 7/3/17. Regular rate after 7/3/17 SVU Annual Conference Registration
Home
Please check if this applies to you: Member of a SVU Affiliated Chapter: Chapter Name:___________________
Regular Exhibitor Registration
Work
First time attendee
$350
Non-member: send SVU membership information and application ARDMS/CCI Number ______________
Payment Check enclosed (check payable to “SVU” drawn on a US bank, net of all bank charges)
Friday, August 4, 2017
Credit Card:
REGISTRATION REQUIRED
MC
Visa
Amex
Card #: __________________________ Technology Theater
Billing Address_____________________ _________________________________ Expires:___________
No Fee
_
Signature: ________________________
Mail to: SVU 4601 Presidents Dr. #260 Lanham, MD 20706 or fax to:301-459-5651 (credit card payment only)
Technology Theater SHOWCASE: 7:00 am - 9:00 am
Confirmation: Written confirmation will be issued once paid registration is received. Refunds: All requests for refunds must be in writing. Requests received by July 3, 2017 are subject to a $75 cancellation fee. No refunds will be issued for cancellations received beginning July 3, 2017; only credit toward a future SVU education program within 12 months.
-
TOTAL CONFERENCE AMOUNT
$
Substitutions: If the registrant is unable to attend, substitutions are welcome and can be made at anytime, including on-site.
Registrant information
Mr.
Mrs.
Ms.
Work:
Dr.
Address ______________________________________________
Name ________________________________________________________
City / State / Zip ________________________________________
Degree(s) / Credentials __________________________________________
Phone _________________________ Fax __________________
Job Title ______________________________________________________
Home: Address ______________________________________________ City / State / Zip ________________________________________
Institution ____________________________________________________ E-mail
Phone _________________________ Fax __________________
______________________________________________________
Special needs due to disability or special meal request:
YES
Preferred Mailing Address:
NO
Fees are listed: Early Rate on or before 7/3/17. Regular rate after 7/3/17 SVU Annual Conference Registration
Home
Please check if this applies to you: Member of a SVU Affiliated Chapter: Chapter Name:___________________
Regular Exhibitor Registration
Work
First time attendee
$350
Non-member: send SVU membership information and application ARDMS/CCI Number ______________
Payment Check enclosed (check payable to “SVU” drawn on a US bank, net of all bank charges)
Friday, August 4, 2017
Credit Card:
REGISTRATION REQUIRED
MC
Visa
Amex
Card #: __________________________ Technology Theater
Billing Address_____________________ _________________________________ Expires:___________
No Fee
_
Signature: ________________________
Mail to: SVU 4601 Presidents Dr. #260 Lanham, MD 20706 or fax to:301-459-5651 (credit card payment only)
Technology Theater SHOWCASE: 7:00 am - 9:00 am
Confirmation: Written confirmation will be issued once paid registration is received. Refunds: All requests for refunds must be in writing. Requests received by July 3, 2017 are subject to a $75 cancellation fee. No refunds will be issued for cancellations received beginning July 3, 2017; only credit toward a future SVU education program within 12 months.
-
TOTAL CONFERENCE AMOUNT
$
Substitutions: If the registrant is unable to attend, substitutions are welcome and can be made at anytime, including on-site.
