CRSTC Registration Form Template - PDF

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CRSTC Registration Form Template - PDF Powered By Docstoc
					Clinical Research Single Topic Conference

CIRCULATORY AND RENAL FAILURE IN CIRRHOSIS: Mechanisms and Emerging Therapies
REGISTRATION FORM
Please print clearly

FAX TO: 703-299-9622

DEADLINE: AUGUST 1, 2008
AASLD Member: No Yes: ID# ____________

_______________________________________________________________________________________________________ Name: LAST (FAMILY NAME), FIRST, MIDDLE INITIAL

CONFERENCE RATES
_______________________________________________________________________________________________________ NICK NAME (FOR BADGE)

(Meeting Code: 4770-42042) Please check the appropriate rate based on your affiliation AASLD Member …....……………………………………………. $ 220 AASLD Trainee Member ….…………………………………….. $ 160

WORK ADDRESS
_______________________________________________________________________________________________________ TITLE

AASLD Associate Member ……….…………………………….. $ 160 Non-member Industry (Pharma) ………….……………………. $ 550 Non-member ………………………….………………………….. $ 330 Non-member Trainee ……………….…………………………… $ 260

_______________________________________________________________________________________________________ COMPANY

Non-member Associate .…………….…………………………… $ 260

PLEASE CHECK ONE
_______________________________________________________________________________________________________ DEPARTMENT Yes, I will utilize the housing package/CMP rate at the Emory Conference Center Hotel (call 800-933-6679 or 404-712-6000 to make your reservation—refer to AASLD meeting.)

_______________________________________________________________________________________________________ STREET

No, I will not require a sleeping room at the Emory Conference Center Hotel and enclosed with my registration payment are my facility fees. Day (s) I plan to attend: (Check all that apply) Saturday ………………………………………………………. $ 95

_______________________________________________________________________________________________________ STREET

_______________________________________________________________________________________________________ CITY, STATE, ZIP CODE, COUNTRY

Sunday ………………………………….. ………………….

$ 95

* The facility fess only apply if you are NOT staying at the Emory Conference Center Hotel

DAYTIME CONTACT INFORMATION (PLEASE LIST ALL) METHOD OF PAYMENT
_______________________________________________________________________________________________________ PHONE Check enclosed, payable to AASLD (drawn on a US bank and in US funds) Charge my: _______________________________________________________________________________________________________ FAX Visa MasterCard American Express

___________________________________________________________ _ACCOUNT # EXPIRATION DATE

_______________________________________________________________________________________________________ EMAIL

___________________________________________________________ _BILLING ZIP CODE (US ONLY)

By registering for this conference, you give AASLD permission to print your name and contact information in the course handouts.

___________________________________________________________ _CARDHOLDER NAME (PRINT)

_____ If you require special assistance to fully participate, please check here and include a full description of your needs with this registration. AASLD fully complies with the American with Disabilities Act’s rules and regulations.

___________________________________________________________ _CARDHOLDER SIGNATURE

HOUSING INFORMATION

DEADLINE: AUGUST 1, 2008

The Emory Conference Center Hotel :: 1615 Clifton Road, Atlanta Georgia :: 800-933-6679 or 404-712-6000
The conference will be held at the Emory Conference Center Hotel in Atlanta, Georgia—a beautiful campus tucked away in a pristine forest located only 30 minutes from the Hartsfield –Atlanta International Airport. Attendees registered for the conference are encouraged to stay at the Emory Conference Center Hotel in order to participate fully in the educational and collegial activities. Staying at the conference center will provide you with opportunities to continue discussions with your colleagues through dinner, in the lounges, and throughout the Emory grounds. The AASLD housing package is based on a “Complete Meeting Package” or CMP. Our rate is a great value. It includes hotel accommodations, conference center facility fees, and a meal plan. NOTE: the meal plan starts with dinner your first night, and ends with lunch on your checkout day. You will be entitled to full breakfast, lunch, and dinner in the hotel dining room. Guests that choose to stay outside the housing package/CMP at the Emory Conference Center Hotel will be assessed a daily fee of $95. This charge covers the use of conference center facilities, light continental breakfast, lunch, and refreshments, but does not include dinner. Other housing rate quoted (online, travel agency, etc.) do not reflect the AASLD housing package, and will require payment of conference center fees of $95 per day. Package Rates: $249 single occupancy, per night, per person and $ 189 double occupancy, per night, per person (or $378 per night, per room) All rates are non-commissionable. Attendees must be registered for the conference prior to making hotel reservations. When calling to arrange accommodations, reference the meeting code “AASLD.” Credit card guarantees are required. Cancellations: Please refer to the Emory Conference Center Hotel’s cancellation policy.