Register for LAACC Annual Meeting
*
- required
*
Full Name:
(as you wish it to appear on your name badge)
*
Degree:
Other
MD
MD, FACC
DO
PhD
RN
NP
PA
Or:
*
Hospital or Practice
Affiliation:
(as you wish it to appear on your name badge)
Address:
City / Zip:
Phone:
-
-
x
Fax:
-
-
*
Email:
*
Register me for the
following:
Friday, Welcome Reception & Poster Competition
Saturday, Continental Breakfast
Saturday, Scientific Meeting
Saturday, Lunch (list dietary restrictions)
Other:
My Guest(s):
I wish to register my spouse/guest for the Welcome Reception and Poster Competition.
Spouse/Guest Name:
Registration Fees:
Chapter member physician, FIT, CCA and Medical Students -- no registration fee
Non-Members--$150.00
Payment:
Payment can be made by check or credit card. No refunds after
Monday, September 15th.
Credit Card Payments:
click here to download credit card authorization form
Mail payment to: PO Box 23512, NOLA 70183.
Form Generated by FORMgen
