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REGISTRATION FORM, 2011—Page Two
REGISTRATION FORM CONTINUED
9. PLEASE PROVIDE YOUR NAME ON THIS PAGE TO ENSURE YOUR REGISTRATION FORM REMAINS TOGETHER:
First Name _______________________________________
Last Name: ______________________________________________
10. CHOOSING REGISTRATION FEES: CIRCLE YOUR CHOICES AND TOTAL
Registraon fees are categorized by member fees, non‐member fees and trainee fees. Choose early bird fees if registering before February 28 (members
only). Choose regular fees if registering between March 1 to March 31. Choose onsite fees if registering aer April 1st.
MEMBER FEES
FOUR‐DAY CONFERENCE PACKAGE—APR 13‐16
PAIN EDUCATION DAY, APRIL 14 ONLY
EARLY BIRD FEE, BEFORE FEB 28 REGULAR FEE MAR 1—MAR 31 ONSITE FEE FROM APRIL 1
575.00 635.00 800.00
220.00 270.00 350.00
TWO‐DAY SCIENTIFIC PROGRAM—APR 15 AND 16 385.00 405.00 500.00
\
ONE DAY FEES, EITHER APRIL 15 OR APRIL 16
300.00 325.00 375.00
NON—MEMBER FEES
FOUR‐DAY CONFERENCE PACKAGE—APR 13‐16
PAIN EDUCATION DAY, APRIL 14 ONLY
TWO‐DAY SCIENTIFIC PROGRAM—APR 15 AND 16
ONE DAY FEES, EITHER APRIL 15 OR APRIL 16
TRAINEE FEES
FOUR‐DAY CONFERENCE PACKAGE—APR 13‐16
PAIN EDUCATION DAY, OR ONE DAY SCIENTIFIC
APRIL 14 OR APRIL 15 OR APRIL 16
TWO‐DAY SCIENTIFIC PROGRAM—APR 15 AND 16
11. FEE TOTALS:
Registraon fees as selected
EARLY BIRD FEE, BEFORE FEB 28 REGULAR FEE TO MAR 31 ONSITE FEE FROM APRIL 1
NA 680.00 855.00
NA 295.00 380.00
NA 450.00 550.00
NA 395.00 450.00
EARLY BIRD FEE, BEFORE FEB 28 REGULAR FEE TO MAR 31 ONSITE FEE FROM APRIL 1
NA 200.00 245.00
NA 150.00 195.00
NA 170.00 215.00
$ _____________________
Peller Estates Winery Event, _______# ckets x $45.00 $ _____________________
Sit‐Down Dinner Guest Ticket, _______# ckets x $75.00
Membership Fee, Regular ($135.00)
Membership Fee, Trainee ($45.00)
SUB TOTAL OF FEES:
HST APPLICABLE ON ALL FEES, 13%
TOTAL FEES:
$ _____________________ Only for guests—if you are a delegate this is complimentary
$ _____________________
$ _____________________
$ _____________________
$ _____________________ #130451156rt001 (If exempt, please contact the office)
$ _____________________
12. PAYMENT
A. By credit card—FAX TO 1‐905‐404‐3727: AMEX ____ VISA _____ MASTERCARD _____
Credit card payments will be processed by Events In Sync, Inc. and your statement will indicate such. Events In Sync, Inc. is the management company for the Canadian Pain Society.
NAME ON CARD: ________________________________________________ NUMBER: ______________________________________________________________ EXPIRY __________________
CVN: ________________________ SIGNATURE: ______________________________________________________________________________________________________________________
B: By Mail: With cheque to: Canadian Pain Society, 1143 Wentworth Street West, Suite 202, Oshawa, ON L1J 8P7, made payable to: Canadian Pain Society
13. QUESTIONS
Georgina Smith, Registraon Manager—georgina@canadianpainsociety.ca; georgina@eventsinsync.com; georgina@gdsmithevents.com; T: 905‐404‐9545
Canadian Pain Society Annual Conference—Program and Registraon Guide Page 25