ANNUAL MEETING REGISTRATION FORM
ANNUAL MEETING REGISTRATION FORM MID-ATLANTIC SECTION – AUA
Fax to: 410-689-3912 Register online at www.MAAUA.org A U A I D NUMB E R (IF K N O WN) L A S T / F A M ILY N A ME
FIRST
M ID D L E IN ITIA L
H O S P I T A L OR IN STIT U TION
S PEC IA L TY
S T R E E T / P O B O X
C ITY
STATE
COUNTRY
C R ED EN TIA L S
POS TA L C OD E
C E L L P H ON E
EM A IL
ATENDEE REGISTRATION Register Early and Save!
ONE-DAY APP MEETING – SATURDAY ONLY
$375
$475
$275
$375
$450
$550
$225
$325
$0.
$0
by 1/26/2018 Advanced Practice Provider
$100
after 1/26/2018 $125
Includes meeting registration for Saturday APP Meeting only. Social events are not included.
Meeting registration includes (1) ticket for social events: Welcome Reception, Themed Reception and President’s Banquet.
Registration Fees Total:
$
Guest Registration Total:
$
GUEST REGISTRATION Guest Registration for Full Meeting*
$200
Guest Ticket for Themed Reception
$100
Guest Ticket for President’s Banquet
$100
G U E S T N A ME(S)
* Guest registration for full meeting includes (1) ticket for social events and a breakfast voucher each morning.
EM AIL ADDRES S
PAYMENT INFORMATION Full payment must accompany all registration forms. Registration forms received without full payment will be returned for completion. Mail to: Mid-Atlantic Section – AUA 1000 Corporate Blvd. Linthicum, MD 21090
Total Amount Due: $ Check Enclosed
Check # ______________
(Check Payable to Mid-Atlantic Section. Payable in U.S. dollars, drawn on a U.S. bank)
For Credit Card Payments Visit www.MAAUA.org or call 1-800-908-9414 to register over the phone. Cancellation Policy: All requests for cancellations must be received in writing to [email protected]. If a written request of cancellation is received prior to January 31, 2018, the registration amount, less a $50 administrative fee, will be refunded after the meeting. Refund requests after January 31,2018, will not be honored.
Fax to: 410-689-3912 Register online at www.MAAUA.org A U A I D NUMB E R (IF K N O WN) L A S T / F A M ILY N A ME
FIRST
M ID D L E IN ITIA L
H O S P I T A L OR IN STIT U TION
S PEC IA L TY
S T R E E T / P O B O X
C ITY
STATE
COUNTRY
C R ED EN TIA L S
POS TA L C OD E
C E L L P H ON E
EM A IL
ATENDEE REGISTRATION Register Early and Save!
ONE-DAY APP MEETING – SATURDAY ONLY
$375
$475
$275
$375
$450
$550
$225
$325
$0.
$0
by 1/26/2018 Advanced Practice Provider
$100
after 1/26/2018 $125
Includes meeting registration for Saturday APP Meeting only. Social events are not included.
Meeting registration includes (1) ticket for social events: Welcome Reception, Themed Reception and President’s Banquet.
Registration Fees Total:
$
Guest Registration Total:
$
GUEST REGISTRATION Guest Registration for Full Meeting*
$200
Guest Ticket for Themed Reception
$100
Guest Ticket for President’s Banquet
$100
G U E S T N A ME(S)
* Guest registration for full meeting includes (1) ticket for social events and a breakfast voucher each morning.
EM AIL ADDRES S
PAYMENT INFORMATION Full payment must accompany all registration forms. Registration forms received without full payment will be returned for completion. Mail to: Mid-Atlantic Section – AUA 1000 Corporate Blvd. Linthicum, MD 21090
Total Amount Due: $ Check Enclosed
Check # ______________
(Check Payable to Mid-Atlantic Section. Payable in U.S. dollars, drawn on a U.S. bank)
For Credit Card Payments Visit www.MAAUA.org or call 1-800-908-9414 to register over the phone. Cancellation Policy: All requests for cancellations must be received in writing to [email protected]. If a written request of cancellation is received prior to January 31, 2018, the registration amount, less a $50 administrative fee, will be refunded after the meeting. Refund requests after January 31,2018, will not be honored.
