9 10 4 9 NOA 100 CNN Center NW, Atlanta, GA 30303

CONVENTION REGISTRATION - PAYMENT FORM

NOA

2019 Annual Convention & CE Program July 10-14, 2019 Register & Pay Online at:

Omni Atlanta Hotel at CNN Center 100 CNN Center NW, Atlanta, GA 30303 Reference NOA

Questions? Call 1-877-394-2020 or Email: mainoffice@

REFUND POLICY

All registration cancellations and refund request must be made in writing by May 15, 2019.

For continuing education attendees, a refund of the registration fee, minus $100 administrative fee, will be given for cancellations received by this date.

Submit all refund request via email to mainoffice@

NOA regrets that refunds will not be given for no shows

REGISTRATION

NAME

DEGREES

ARBO #

ADDRESS

CITY

ST

ZIP

CELL

EMAIL

EMERGENCY CONTACT

PHONE

DIET/MOBILTIY RESTRICTIONS

Wheelchair Vegetarian No Seafood No Peanuts Other

SCHOLARSHIP FUND - Dr. Will Kelley's Memorial Fun Run is a scholarship fundraiser. Yes, I donated $20 or more and will receive a T-shirt * Select Size: S - M - L - XL - 2XL - 3XL

# of Fun Run Participants

Check all that apply: I donated online at . I enclosed a check for the scholarship fund, payable to NOF. Indicate the NOF amount for your tax-deductible contribution for the scholarship fund here

NOF AMT

GUEST NAME

12 & Under

DEGREES

PAYMENT CALCULATION & PROCESSING

ARBO #

FUN RUN PARTICIPANT

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

*SHIRT SIZE

DIET/ MOBILITY/ RESTRICTIONS

Early Bird Registration Ends April 15th

Regular Registration April 16 -June 10

$50 Fee for Onsite Registration

PACKAGES Member ? OD Non-Member OD Student (NOSA Track) Assoc/Affiliate/Guest Youth CE Only - Standard CE CHOICE- Friday Only CE CHOICE- Saturday Only Residents

Early Bird Regular Onsite # Sub Total

$500 $600 $700

$

$650

$700 $750

$150 $175 $225

$

$270 $320 $370

$

$100 $125 $175

$

$320 $345 $395

$

$200 $250 $300

$

$200 $250 $300

$

$200

$250 $300

ADDITIONAL EVENT TICKETS - After purchase of (1) standard package

Welcome Reception

$80

X

= $

Awards Banquet

$100 X

= $

Awards Banquet NOSA Member Rate NOF Golf Tournament

NOA Scholarship FUN RUN donation *

$50 X $175 X $20 X

= $ = $ = $

*Note: ? ?

Golf Tournament is NOT included in registration.

T-shirts are only for Fun Run participants with donations of $20 or more.

ADDITIONAL EVENTS TOTAL $ PACKAGE TOTAL $

TOTAL AMOUNT DUE $

CHECK

Make check payable to National Optometric Association (Write name of primary attendee from business checks in the memo)

CARD #

CVV Code _______ EXP ______ SIGNATURE ________________________________

MAIL FORM TO The National Optometric Association, 5009 Beatties Ford Rd Ste. 107 #278, Charlotte, NC 28216

FAX FORM TO EMAIL TO QUESTIONS?

877-472-3492 mainoffice@ Call 877-394-2020 Ext 101 for more information

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