2017_ACOG_preliminary_program

AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
REGISTRATION FORM
Step 1A. Registrant Information (Please Print)
First Name __________________________________________ Last Name__________________________________________________ ACOG ID # ___________________________
Name as it should appear on badge
First Name or Nickname_____________________________________ Last Name __________________________________________ Degree______________________________
Address______________________________________________ City____________________________ State/Province___________ Zip_______________ Country_____________
Daytime Phone Number_____________________________________Fax _________________________________________ Email Address _________________________________
Your contact information can be passed on to exhibitors at ACOG 2017 so they can contact you regarding product demonstrations, industry- sponsored
symposiums and special events taking place during the Annual Clinical and Scientific Meeting, giveaways, or invitations from Exhibitors. Please indicate
your preference below:
® No, I am not interested in receiving any information or invitations from exhibitors. ® Yes, please allow exhibitors to contact me.
Which of the following best describes your primary practice focus?
® Ob-Gyn
® Ob Only
® Gyn Only
® Maternal-Fetal Medicine
® Gynecologic Oncology
® Primary and Preventive Care
® Reproductive Endocrinology and Infertility
® Urogynecology and Pelvic Reconstructive Surgery
What is your job function? ___________________________________________________________________________________________________________________________
What Medical School did you attend? ________________________________________________________________________________________________________________
Emergency Contact Name_________________________________________________________________________ Phone Number_____________________________________
Step 1B. Spouse/Guest Registration
If you would like to register a spouse/guest, please list the name below and include payment with your registration fee. Spouse or guest
must be linked with an Annual Meeting registrant. To register more than one spouse/guest, please make a copy of this form.
First Name or Nickname___________________________________________Last Name_____________________________________________________________
City________________________________________________________________State/Province ________________________________________________________
Step 2. Registration Fees
Included in full registration for the
2017 Annual Clinical and Scientific
Meeting are complimentary
Colloquia, Clinical Seminars, Cutting-
Edge Topics, Subspecialty Sessions,
Surgical Tutorials, Live Telesurgery,
Flipped Classrooms, Film Festival,
and the Welcome Reception. For
one-day registration, the events
occurring that day are inclusive in
the fee.
Early Bird Rate:
December 5, 2016 -
January 31, 2017
Advance Rate:
February 1 - April 7, 2017
On-Site Rate:
April 8 - May 9, 2017
Early Bird Advance After April 7 Cost
ACOG Fellow $600 $650 $700
ACOG Junior Fellow in Practice $600 $650 $700
ACOG Junior Fellow in Training $400 $480 $515
ACOG Life Fellow/Fellow Senior Status $380 $455 $485
ACOG Member on Active Duty in the US Military $390 $390 $390
ACOG Associate Member $580 $625 $670
ACOG Associate Member International - Organization $670 $580 $625
ACOG Educational Affiliate $580 $625 $670
Education Affiliate - Organization $625 $580 $670
ACOG Honorary Fellows $625 $700 $750
Resident, Non-Member $845 $920 $985
Physician, Non-Member $845 $920 $985
Other Healthcare Professional $870 $935 $1,000
Medical Student $25 $25 $25
Spouse/Guest $190 $200 $225
Practice Manager, Non-Member $625 $700 $750
One-Day Registration – ACOG Fellow $340 $365 $400
One-Day Registration – ACOG Junior Fellow in Practice $340 $365 $400
One-Day Registration – ACOG Junior Fellow in Training $225 $250 $280
One-Day Registration – Fellow Senior Status $215 $235 $255
One-Day Registration – ACOG Active Duty in the US Military $160 $160 $160
One-Day Registration – ACOG Associate Member $325 $350 $375
One-Day Registration – ACOG Associate Member International - Organization $325 $350 $375
One-Day Registration – ACOG Educational Affiliate $325 $350 $375
One-Day Registration – ACOG Education Affiliate - Organization $325 $350 $375
One-Day Registration – ACOG Honorary Fellows $350 $400 $450
One-Day Registration – Physician, Non-Member $475 $515 $550
One-Day Registration – Other Healthcare Professional $485 $525 $560
One-Day Registration – Practice Manager, Non-Member $350 $400 $450
One-Day Registration – Resident, Non-Member $475 $515 $550
Registration Fee Subtotal $
WWW.ACOG.ORG
O
Obstetrics
G
Gynecology
P
Practice
AMERICAN COLLEGE of OBSTETRICIANS and GYNECOLOGISTS
2017 Annual Clinical and Scientific Meeting
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