32nd ASLMS Annual Conference - American Society for Laser ...

BADGE INFORMATION
2012 Annual Conference
Pre-Conference Courses: April 18-19, 2012
Annual Conference: April 20-22, 2012
Gaylord Palms TM Resort and Convention Center
Kissimmee, FL
Last (Family) Name: Degree (i.e. M.D., Ph.D.):
First (Given) Name: Middle Initial:
Professional Affiliation/Institution: Specialty:
Address:
ASLMS Conference
Registration Form
One form per registrant (PLEASE PRINT) or
register online at www.aslms.org
City: US State/Canadian Province: Zip:
Country: Postal Code:
Telephone: Fax: Email:
Emergency Contact Name: Telephone:
Cell Phone: (If needed, will be used only for emergency purposes during conference)
Are you a member of the North American Association of Laser Therapy (NAALT)? Yes No
Are you a member of the Head and Neck Optical Diagnotics Society (HNODS)? Yes No
Are you a member of the PanAmerican Photodynamic Association? Yes No
Do you or anyone attending with you require disabled or other services: Yes No (If yes, call 1-877-258-6028)
FULL ANNUAL CONFERENCE – APRIL 20-22, 2012
Annual Conference Registration includes a complimentary lunch on
Friday and Saturday
Payment
Received
Prior to
3/1/12
Payment
Received
after
3/1/12
Member – Includes NAALT, HNODS, and PanAmerican Photodynamic Association
members.
$405.00 $455.00
ASLMS Applicant - Membership application must be completed and submitted
by March 1, 2012. No exceptions.
$405.00 $455.00
Non-Member $650.00 $700.00
Military – Active U.S. military - must present government issued military ID. $455.00 $490.00
Student/Resident - Undergraduate, Graduate, Fellows-in-Training Only. Mail
or fax a letter from your Program Director or Chief of Service on official
letterhead for verification purposes to address on last page of registration form.
N/C N/C
Press – Credentials will be required. N/C N/C
GLOBAL CONFERENCE REGISTRATION
Global Registration includes: Annual Conference, two Thursday courses
AM and PM and the evening Tech Connect Session, one Friday course,
one Saturday course and a complimentary lunch on Friday and Saturday.
Excludes Thursday luncheons, Fundamentals and Nursing/Allied Health courses.
Member – Includes NAALT, HNODS, and PanAmerican Photodynamic Association
members.
ASLMS Applicant - Membership application must be completed and submitted
by March 1, 2012. No exceptions.
Payment
Received
Prior to
3/1/12
Payment
Received
after
3/1/12
$995.00 $1,045.00
$995.00 $1,045.00
Non-Member $1,625.00 $1,675.00
Military – Active U.S. military - must present government issued military ID. $1,140.00 $1,175.00
Enter Course Number Selections (Excludes 008,009,010,012): 1) _______ 2) ________ 3) ________ 4) ________
Total
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