2017 SVU Annual Conference Registration Form
2017 SVU Annual Conference Registration Form Save money! Register by July 3, 2017. Complete and submit a registration form 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). Registration Information Name: Degrees/Credentials: Institution: Special needs due to disability or special meal request: Address: City: State: Phone Number:___________________________________________
Mr. Job Title: E-mail: Yes
Mrs.
Ms.
Dr.
No
Zip:
Additional Information Please check if this applies to you: ARDMS#: CCI#: Yes No First Time Attendee Send SVU membership information and application Nonmember: Check here to opt out of receiving 2017 Annual Conference exhibitor emails Annual Conference Registration Fees Fees are listed: Early rate on or before 7/3/17. Regular Rate after 7/3/17 SVU Member Nonmember Student Member Student Nonmember Fellow
Early/Regular $625/$700 $725/$800 $100/$125 $125/$150 $300/$350
August 4, 2017 Technology Theater 7:15 - 9:15 am Registration Required Technology Theater (no fee) 40th Anniversary Party Additional Guest ($40 fee) Payment
One Day Rate $275/$350 $325/$400 $50/$80 $60/$90 $150/$175
Select Day Thursday Friday Saturday
Total Due:
Check Enclosed (check payable to “SVU” drawn on a US bank, net of all bank charges) MasterCard Visa American Express Credit Card: Credit Card Number: Expiration Date:
Billing Zip:
Signature:
Please mail this form to SVU PO Box 75491 Baltimore, MD 21275-5491 Fax form to 301-459-5651 (credit card payment only) 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 educational program within 12 months. Substitutions: If the registrant is unable to attend, substitutions are welcome and can be made at any time, including onsite.
Mr. Job Title: E-mail: Yes
Mrs.
Ms.
Dr.
No
Zip:
Additional Information Please check if this applies to you: ARDMS#: CCI#: Yes No First Time Attendee Send SVU membership information and application Nonmember: Check here to opt out of receiving 2017 Annual Conference exhibitor emails Annual Conference Registration Fees Fees are listed: Early rate on or before 7/3/17. Regular Rate after 7/3/17 SVU Member Nonmember Student Member Student Nonmember Fellow
Early/Regular $625/$700 $725/$800 $100/$125 $125/$150 $300/$350
August 4, 2017 Technology Theater 7:15 - 9:15 am Registration Required Technology Theater (no fee) 40th Anniversary Party Additional Guest ($40 fee) Payment
One Day Rate $275/$350 $325/$400 $50/$80 $60/$90 $150/$175
Select Day Thursday Friday Saturday
Total Due:
Check Enclosed (check payable to “SVU” drawn on a US bank, net of all bank charges) MasterCard Visa American Express Credit Card: Credit Card Number: Expiration Date:
Billing Zip:
Signature:
Please mail this form to SVU PO Box 75491 Baltimore, MD 21275-5491 Fax form to 301-459-5651 (credit card payment only) 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 educational program within 12 months. Substitutions: If the registrant is unable to attend, substitutions are welcome and can be made at any time, including onsite.
