1
Additional fee may apply.
2
See page 44 for Resident Fellows Forum application information.
3
Spouse and Guest registrants are not permitted to attend Instructional Courses.
4
Registration for Plastic Surgery The Meeting not required.
5
Meeting delegates from the following countries qualify for this category: Australia, Belgium, Brazil, France, Ireland, Israel, New Zealand,
Singapore, South Africa, South Korea, Taiwan, The Netherlands, and United Kingdom.
NOTE: Interested in the Spouse/Guest Program Tours? See page 40 for details.
Terms and Conditions: If registering in a non-member category, you hereby agree to the terms and conditions of the verification and approval process outlined on page 45.
Photo release: As a registrant, you agree to ASPS' use of your likeness captured by the official show photographer and official show videographer in any future promotional meeting materials.
RB13
Fax to: (847) 228-7099
REGISTRATION FORM
________________________________________________
asps member id#
_________________________________________________________________________________________________________________________________________________________________________
last
Name
first
Name
badge
NickName
(listed above full name)
_________________________________________________________________________________________________________________________________________________________________________
address
city
state/prov.
_________________________________________________________________________________________________________________________________________________________________________
zip/postal code
couNtry
_________________________________________________________________________________________________________________________________________________________________________
telephoNe
fax
email
(for confirmation)
_________________________________________________________________________________________________________________________________________________________________________
EmErgEncy contact PErson:
last
Name first
Name
phoNe
if, under the americans with disabilities act
(ada), you require specific aids, devices, or other
accommodations to fully participate in this meeting,
specify:
Wheelchair assisted listening device
other _________________________________________
if you are attending functions or courses with a
plated lunch, specify dietary requirements:
vegetarian kosher
1
Registration Category (see descriptions on page. 44)
Early Bird
8/1
Advance
8/2-9/5
On or
After 9/6
ASPS/ASMS Active Member, Associate, International Member, Life
Inactive Member, and Candidates for Membership
$650
$775
$900
ASPS/ASMS Life Active Member
NO FEE
NO FEE
$200
New! Guest Nation, South Korea (copy of medical license required)
$650
$775
$900
ASPS International Candidate
$650
$775
$900
ASPS/ASMS Resident/Fellow Subscriber
2
(Residents and Fellows
Forum subscription required)
NO FEE
NO FEE
$200
Resident/Fellow non-subscriber
2
(verification from training program
director required)
$325
$385
$450
ASPS International Trainee
5
NO FEE
NO FEE
$200
ASPS Affiliate Member
$285
$370
$495
Plastic Surgery Team Member
$515
$690
$815
ASPS International Partner-Guest Physician
5
$795
$920
$1,040
Guest Physician (copy of medical license required)
$1,135
$1,310
$1,485
Industry Research and Scientific Personnel (subject to verification and
approval by ASPS)
$1,135
$1,310
$1,485
Investment Analyst (subject to verification and approval by ASPS)
$1,135
$1,310
$1,485
Active Military Duty
NO FEE
NO FEE
$200
Medical Students (copy of student ID or letter from medical school
registrar required)
$0
$0
$150
Total Physicians/Medical Personnel Registration Fees $
Spouse/Guest Registration
3
Last Name ________________________________________ First Name ___________________________________
Email _________________________________________________________________________________________
Badge Nickname (first) ___________________________________________________________________________
Indicate registration
Spouse
Guest
Early Bird
8/1
Advance
8/2-9/5
On or After
9/6
Spouse/Accompanying Guest
$175
$200
$250
Life Active Spouse/Accompanying Guest
$125
$150
$200
Total Spouse/Guest Registrant Fees
$
Visa
®
MasterCard
®
AMEX
®
Check payment to ASPS (in U.S. Funds)
Grand ToTal EnclosEd (u.s. Funds only)
$
PaymEnT InFormaTIon
____________________________________________________________________________________________________________
ACCOUNT NUMBER
EXPIRATION DATE
SECURITY CODE
____________________________________________________________________________________________________________
SIGNATURE
NAME OF CARD HOLDER
Instructional Courses (please indicate course
number)
Fee
1
ST
Choice
2
ND
Choice
3
RD
Choice
Total
Fee
Friday 9:00 - 11:00 a.m. (BR101 - PR104)
$135
Friday 9:00 a.m. - 12:00 p.m. (PR120 - PR121)
$175
Friday 9:00 a.m. - 1:00 p.m. (CO130)
$210
Friday 12:00 - 1:00 p.m. (BR140 - CO142)
$85
Friday 2:00 - 4:00 p.m. (BR150 - RE155)
$135
Friday 2:00 - 5:00 p.m. (CR160)
$175
Friday 2:00 - 6:00 p.m. (CO170 - BR172)
$210
Saturday 5:00 - 7:00 p.m. (BR200 - RE211)
$135
Sunday 7:00 a.m. - 8:00 p.m. (BR300 - RE311)
$85
Sunday 4:30 - 6:30 p.m. (BR320 - RE331)
$135
Monday 4:00 - 6:00 p.m. (BR400 - RE411)
$135
Tuesday 7:00 - 9:00 a.m. (BR500 - RE511)
$135
Instructional Course Subtotal
$
Sign up for 3 ICs get 10% OFF. Sign up for 4 or more ICs get 20% OFF IC subtotal
$-
Total Instructional Course Registration Fees
$
Special Programs
4
Fee
(P708) Medical Students Day
No fee
(P900) ASMS The Lower Facial Third Symposium (see page 4 of the registration
brochure for pricing)
(P905) Senior Residents Conference/Residents Day Joint Program
includes courses: PR409 and PR600
Non-subscriber: $350
Subscriber: $475
(P910) Refining Primary Rhinoplasty Results - Minimizing Secondary Rhinoplasty
$400
Total Special Program Fees
All Other Programs and Events
Fee
# of
Tickets
Total
Fee
(P700a) Residents Day
No Fee
(E700b) Resident's Reception
No Fee
(P701) Hot Topics in Plastic Surgery
$250
(P704) VIPS Forum: Surgical Volunteerism - Past, Present and Future
No Fee
(E705) Sheryl Crow Rocks The USS Midway
$500
(P707) Breakfast with Champions (complimentary for medical students)
$30
(P709) Young Plastic Surgeons' Forum Luncheon
No Fee
(P710) Women Plastic Surgeons' Luncheon
$50
(E711) Women Plastic Surgeons' Networking Hour
No Fee
(P712) Life Members' Luncheon
No Fee
(P713) Office Spouse Networking Luncheon
$50
(E714) ASMS Annual Business Meeting and Luncheon (ASMS members)
$50
(P715) How to Get an Article Accepted by PRS/LOE Made Easy Luncheon
$25
(E716) The PSF International and Research Reception (Int'l. registrant/
guest)
No Fee
(E717) The PSF International and Research Reception
(U.S. or Canada registrant/guest)
$65
(E719) San Diego Zoolala: A Wildlife Expedition (adult)
$175
(E720) San Diego Zoolala: A Wildlife Expedition (child)
$95
(E721) ASPS/PSF Annual Business Meeting & Luncheon
(voting ASPS members)
No Fee
(P722) New! Young Plastic Surgeons Forum Service Project
No Fee
(E724) Wrap Party: Jukebox Monday Night
No Fee
(E725) Wrap Party: Jukebox Monday Night (additional ticket)
$95
Total Other Course and Events Fees
$
BarcodE BadGE
remove my phone # remove my fax # remove my email address
SAN DIEGO, OCTOBER 11-15, 2013