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					REGISTRATION FORM – ABSTRACT AUTHORS                                                                            (Page 1 of 2)
  Early Bird Registration Deadline for             Deadline to             Deadline to Register          Registration opens in
           Abstract Authors                      Register by Mail                Online                        Orlando
             May 13, 2010                         June 4, 2010               June 17, 2010                  June 24, 2010

 ADA Registration will e-mail or fax a confirmation of your registration within 72 hours of receipt of your form.
 For accurate and easy registration you may visit http://scientificsessions.diabetes.org to register online.
FAX:       (415) 979-2249         MAIL:       ADA Registration                              QUESTIONS:              Phone: (Mon-Fri, 9am-9pm ET)
                                              c/o CMR                                                               (866) 290-9910 (US & Canada)
                                              33 New Montgomery, Suite 1100                                         (415) 268-2086 (International)
                                              San Francisco, CA 94105                                               E-mail: ada2010reg@cmrus.com
ADA reserves the right to accept, reject or condition acceptance, based on ADA’s sole discretion, for any reason, which need not be disclosed to the applicant. By
registering for this event, attendee agrees to hold harmless ADA and the Facilities for any damages or injuries to property or individuals that may occur during the
conference. Attendee also agrees that ADA may use and distribute your image, name and voice in all forms and media.
Photography, including camera-enabled cellphones, videotaping and audiorecording in session rooms, workshops and the Poster Hall is forbidden.
I. PERSONAL INFORMATION (please print or type clearly)
First Name:                                      Middle Initial:          Last Name:
Academic Degree(s):
   DO     DPM       MD               MD,PhD             NP      PA        PhD         RD        RN        RPH/PharmD            Other (please specify):
Company/Institution (for badge):
Mailing Address (please check one)             Business          Home
Street Address:
City:                                State/Province:          Zip/Postal Code:                 Country:
Phone:                               Fax:                              E-mail*:
Please send a copy of the registration to: Additional E-mail:
In case of an emergency during the meeting, please contact:
First Name:                          Last Name:                                    Phone:
Relationship:                        Will this person be staying in your hotel room?              Yes          No
         Check here if you require special assistance to fully participate in the meeting (please attach a separate sheet to indicate needs).
*E-mail address is required - this unique identifier will be used for tracking continuing education credits.
II. REGISTRATION FEES (please check one)
Abstract Authors are extended the Early Bird Registration rate until May 13, 2010.

                                                     EARLY BIRD                                     ON-SITE
                                                 Between 12/2/09-5/13/10                       Between 5/14/10-6/29/10
ADA Member**                                                $395                                          $515
New or Renewing Member                                      $395                                          $515
Non-Member                                                  $570                                          $705
Student/Resident/Fellow                                     $245                                          $280
 Available to people currently enrolled in one of these programs. Proof of status in program must be supplied by institution along with your registration form.
Guest (Spouse/Family Member)                                  $100                                $100                               $100
         Guest’s First Name:                                 Guest’s Last Name:
 One guest per full meeting registration is allowed. Guest registration includes entrance to the Exhibit Hall, Poster Hall and non-ticketed Social Events only.
 Guests are not eligible for continuing education credit. Children under the age of 18, even if paid registrants, will not be admitted to the Exhibit Hall or Session rooms.
**In order to qualify for the member rate you must list your 15-digit Member ID Number and be a member through June 30, 2010.
III. MEMBERSHIP DUES
ADA Members: Professional Member ID Number -
New or Renewing Members: (Please check one)
Category I: Physicians, researchers, others:                                                Category II: Dietitians, diabetes educators, nurses, others:
Includes one of the two journals listed (choose one):                                       Includes journals - Diabetes Spectrum® and Diabetes Forecast®
       Diabetes®          Diabetes Care®
Regular, US/Mexico                     $295.00                                              Regular, US/Mexico                      $135.00
Regular, Canada                        $309.75 (includes GST)                               Regular, Canada                         $141.75 (includes GST)
Regular, International                 $395.00 (outside North America)                      Regular, International                  $195.00 (outside North America)
In-Training*, US/Mexico                $175.00                                              In-Training*, US/Mexico                 $75.00
In-Training*, Canada                   $183.75 (includes GST)                               In-Training*, Canada                    $78.75 (includes GST)
In-Training*, International            $275.00 (outside North America)                      In-Training*, International             $125.00 (outside North America)

*Training dues rates are reserved for professionals that have received their first professional degree, diploma or certificate within the last 5 years. If you quality for this
special rate, please reference your Training information below.
University or College attended:                                         Degree (s):                                   Date Earned:
Continued (Page 2 of 2)

Attendee Name (first name, middle initial, last name):
IV. ADDITIONAL ITEMS
     2010 Orlando City Pin:                                                     Donation to the ADA Research Foundation: $
           (quantity) x $5.00 = $                                               Donate $20 for a 5K@ADA T-Shirt (must register separately for this
     ‘I Decide’ Charm:                                                      event):
           (quantity) x $9.95 = $                                                    (quantity) x $20.00 = $
     Shuttle Pass (for those who do not book through ADA                     Size (Men’s): XSM        SM      M       L       XL        XXL
Housing):
          (quantity) x $50.00 = $                                             Webcasts: Order now to get the lowest possible price for access to the official
     Opening Reception – Epcot Center (Friday, June 25th):                  webcasts of presentations at Scientific Sessions 2010
     Prior to May 13, 2010 -                                                Members
           Attendee (limit of 1) x $20.00 = $                                     On-line access only - $160.00 = $
           Registered Guest (limit of 1) x $20.00 = $                             On-line access with USB - $215.00 = $
           Non-Registered Guests (limit of 3) x $40.00 = $                        On-line access with USB and mailed via DHL - $245.00 = $
     After May 13, 2010 -                                                   Non-Members
           Attendee (limit of 1) x $35.00 = $                                     On-line access only - $210.00 = $
           Registered Guest (limit of 1) x $35.00 = $                             On-line access with USB - $265.00 = $
           Non-Registered Guests (limit of 3) x $50.00 = $                        On-line access with USB and mailed via DHL - $315.00 = $

V. PROFESSIONAL INFORMATION (please check one answer to each question)
Please list your Abstract Publication Number(s):
Please indicate type of Abstract Author:    Oral                             Poster                         President Poster
I consider myself primarily a:              Clinician                        Educator                       Industry             Scientist
Specialty Area:                             Adult Endocrinology              Basic Science                  Cardiology          Dietetics
                                            Epidemiology                     Family Practice                Geriatrics          Internal Medicine
                                            Nephrology                       Neuropathy                     Nursing             Obstetrics/Gynecology
                                            Ophthalmology                    Pediatric Endocrinology        Pharmacy            Podiatry
                                            Psychology                       Public Health                  Other (please specify):
Place of work:                              Academic                         Administration                 Corporate/Industry
                                            Government/Military              Hospital                       Managed Care
                                            Private Practice                 Other (please specify):
Which session track are you                 Acute and Chronic Complications              Behavioral Medicine, Clinical Nutrition, Education, Exercise
most interested in?                         Clinical Diabetes/Therapeutics               Epidemiology/Genetics
                                            Immunology/Transplantation                   Insulin Signaling/Insulin Action
                                            Integrated Physiology or Obesity             Islet Biology/Insulin Secretion
Scientific Sessions Attendance:                Attend only East Coast         Attend every 2-3 years        Attend each year                 First Time
How did you learn about this meeting?        ADA E-News                     ADA Web Site                    Colleague           Journal Advertisement
                                             Mailing                        Previous Attendance             Other (please specify):
 If referred by a colleague, please provide the first and last name of the colleague:
 If by mailing, enter the registration code listed on the brochure below your address:
VI. PAYMENT INFORMATION
Registration Fees $        .      + Membership Dues $             .        + Additional Items $         .       = Total Amount Due $                .
Checks and money orders must be payable to the American Diabetes Association and must be drawn on a U.S. bank, in U.S. dollars.
    Check/Money Order #______           Visa        MasterCard          Discover      American Express
Credit Card Number:                                              Exp. Date (MM/YY):              /
Billing Street Address:                                                     Billing Zip/Postal Code:
Name as it appears on card:                                                 Signature:
VII. CHANGES OR CANCELLATIONS
 Name changes and substitutions are not permitted.
 All cancellation and refund requests must be made in writing and sent via e-mail to ada2010reg@cmrus.com or faxed to (415) 979-2249.
 For a full refund (less a $50 administrative fee) cancellation requests must be received on or before March 11, 2010.
 Cancellation requests received between March 12, 2010 and May 13, 2010 will receive a refund of 50% of the registration fee.
 Cancellation requests received after May 13, 2010 will not receive a refund of the registration fee.
 Abstract Authors who register early but their abstract is not accepted for presentation may cancel the registration and receive a full refund (less a
  $50 administrative fee) up to May 13, 2010.
 City Pins,‘I Decide’ Charms, and ADA Research Foundation donations are non-refundable.
 Webcasts and Shuttle Passes will be fully refundable if cancelled prior to June 24, 2010.
 Opening Reception tickets and 5K@ADA T-Shirts will be fully refundable if cancelled prior to May 13, 2010. Cancellations after May 13, 2010
  will receive a refund of 50% of the value of the ticket or shirt.
 All attempts will be made to process refunds within 30 days of receipt.
 ADA will correct any errors when calculating the total amount due.

				
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