Early Bird Deadline: Tuesday, March 1, 2005



For security reasons, badges will be required for all ASA meetings & events. For designated events, tickets will also be issued & must be presented for admittance. Pre-registered attendees may pick-up their badges & tickets at the ASA Registration Desk at the Philadelphia Marriott Downtown beginning Wednesday afternoon, April 19, 2017. Registration fees include the cost of the Annual Banquet (black tie preferred).Please Print or TypeIndicates Required Field FORMTEXT ?????Name FORMTEXT ?????Institution FORMTEXT ?????Address FORMTEXT ?????City FORMTEXT ????? FORMTEXT ?????StateZIP FORMTEXT ?????Country FORMTEXT ?????Phone (Daytime) FORMTEXT ?????Fax FORMTEXT ?????Email FORMTEXT ?????Name of Spouse/Partner/Non-Physician Guest (if registering) FORMCHECKBOX Please contact me regarding special needs.Cancellation Policy:All requests for cancellations must be received in writing. If a written request of cancellation is received at the Association’s Administrative Office prior to April 5, 2017, the registration fee, less a $50.00 administrative fee, will be refunded after the meeting. Refund requests received after April 5th will not be honored. Fees cannot be reduced for partial attendance. Please send written requests to:ASARegistration Department500 Cummings Center, Suite 4550Beverly, MA 01915FAX: 978-524-0461REGISTRATION FEES (in USD):(Each meeting registration fee includes one ticket for the Annual Banquet)QtyRegistrant TypeEarly BirdDeadline: 03/17/2017Regular FeeTotal FORMTEXT ?????Fellow$475$525$ FORMTEXT ????? FORMTEXT ?????Honorary FellowComplimentaryComplimentary$ FORMTEXT ????? FORMTEXT ?????Invited Non-Member Physician$525$575$ FORMTEXT ????? FORMTEXT ?????Resident$345$345$ FORMTEXT ????? FORMTEXT ?????Spouse/Partner/Non-Physician Guest$245$245$ FORMTEXT ?????Optional Barnes Foundation Tour & Box Lunch (recommended for Spouses/Partners/Non-Physician Guests) FORMTEXT ?????incl. visit to Samuel Gross Monument April 21, 9:30a-12p$95$95$ FORMTEXT ?????TOTAL FEES$ FORMTEXT ????? FORMCHECKBOX I/We will be attending the Annual Banquet on Friday, April 21, 2017 (black tie preferred).PAYMENT INFORMATION:Fees are payable via VISA, MasterCard, American Express, check, or money order. Please indicate your payment method below. FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CHECK (enclosed) FORMCHECKBOX MONEY ORDER (enclosed)Amount Authorized: FORMTEXT ?????Name (as it appears on card): FORMTEXT ?????Credit Card #: FORMTEXT ?????Expiration Date: FORMTEXT ????? / FORMTEXT ?????Security Code: FORMTEXT ?????(See card images below.)Your credit card’s security code is a 3- or 4-digit number located on the front or back of your credit card.Full Billing Address: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature: ................
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