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ALL PAYMENTS MUST BE MADE IN U.S. DOLLARS
Name
               First                  (Mi)                  Last                    
Title
Address
City
State
Zip Code
Office Phone
Home Phone
Fax ex 650-555-1212 x1234
Email
Payment Information
Check/Money Order
 Amount Enclosed $  

If you make a mistake in your selection below , please uncheck Appropriate Box To Clear

Please check applicable box on left and then check applicable price box.
      Subtotal
Renew Full Membership $365
 $
Renew Associate Membership $100
 $
    Pre Registration On site Registration    
Physicians/Dentists Member $275 $350 $
Physicians/Dentists Non-member $350 $450 $
Physicians/Dentists Practicing in UK.Middle East ,etc. $150 $250 $
Fellows, RNs, PAs, Pharmacists $100 $200 $
Residents, Interns $50 $150 $
Students/Guests N/C $100 $
Spouses, Non-Medical Personnel, Other $150 $250 $
   
No of persons
    
Annual Banquet $80/ person $
Grand Picnic   $30/person
      Under 6 yrs N/C		 $
Golf Tournament $115/ person
 $
Carowinds Theme Park $47.50/ person
 $
Concord Mills Shopping $20/ person
 $
Total $

ALL PAYMENTS MUST BE MADE IN U.S. DOLLARS