| Registration Information | |||
Name (last, first)_____________________________________Degree____________ Title/Position____________________________________Dept.__________________ Institution/Organization_________________________________________________ Address__________________________________________________________________ City/State/Zip_____________________________________Country_______________ Phone____________________________________Fax_____________________________ E-mail___________________________________________________________________ |
| Advance Registration Fees | |||||||||||||||
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| Events (included in registration fee) | |||||||||||||||
| Do you plan to attend the Welcome Reception & Banquet? | ____Yes ____No | ||||||||||||||
| Do you plan to attend the Wenesday Luncheon? | ____Yes ____No | ||||||||||||||
| Do you plan to attend the Thursday Luncheon? | ____Yes ____No | ||||||||||||||
| Additional Guest Tickets | |||||||||||||||
| Welcome Reception & Banquet | #_____ x $50 each = ______$ | ||||||||||||||
| Wednesday Luncheon | #_____ x $30 each = ______$ | ||||||||||||||
| Thursday Luncheon | #_____ x $30 each = ______$ | ||||||||||||||
| Tutorial Registration (Optional; please select no more than one) | |||||||||||||||
| Advance: $195 On-Site: $245 | |||||||||||||||
| T1_______ T2______ T3_______ | ______$ | ||||||||||||||
| Complementary Tour Choice: Tour A___ Tour B___ Tour C___ | |||||||||||||||
| TOTAL ENCLOSED OR TO BE CHARGED ______$ | |||||||||||||||
| Payment Information | |||||||||||||||
| Payment must be in U.S. dollars payable through a U.S. bank. | |||||||||||||||
| Make checks payable to AMIA. | |||||||||||||||
| Check enclosed in the amount of __________$ | |||||||||||||||
| Please charge my credit card in the amount of __________$ | |||||||||||||||
Card number_____________________________________________Exp.______/______ Signature________________________________________________________________ | |||||||||||||||
| Additional Information | |||||||||||||||
| Badge Information | |||||||||||||||
| This is how your badge will read. If information is the same as that above, skip this section. | |||||||||||||||
Name/Degree______________________________________________________________ Organization_____________________________________________________________ City/State/Country_______________________________________________________ | |||||||||||||||
| Instructions | |||||||||||||||
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Submitting Your Advance Registration: AMIA will not process registrations received without payment. Registrations received after May 9 will be charged at the on-site registration rates. Send this registration form to the address listed above or fax it to the number above; you may fax only if you are using a credit card or purchase order for payment.
Advance Registration: Advance registration discounts apply to all registrations received by AMIA, and paid in full, by May 9, 2000. Registrations not paid in full by May 9, 2000, will be charged the on-site registration rate. Any attendee with an outstanding balance must pay it before registration materials may be obtained. AMIA will confirm advance registrations within approximately two weeks of receipt of payment. The registration fee includes all congress activities, including a ticket to the Welcome Reception & Banquet, and Wednesday and Thursday luncheons, and a copy of the Spring Congress attendee list.
Discounted AMIA Member Rates*: Congress registrants who are paid AMIA members for 2000 qualify for the member rate. (Associate Members do not qualify.) If you are not an AMIA member and would like to join to receive the discounted membership registration fee, you may download a membership application from AMIA's Web site at www.amia.org or call 301-657-1291 to request one by fax.
Student Registration**: Student registrations must be accompanied by proof of student status (e.g., a letter from a school or department official verifying status). For registrations received without proof of student status, AMIA will charge regular member/non-member registration rates.
Payment: Payment must be in U.S. currency and payable through a U.S. bank. Accepted forms of payment include personal or company check, money order, VISA, MasterCard, or American Express. Other credit cards are not accepted.
Transfer Policy: Registrants who are unable to attend the Spring Congress may transfer their registration by notifying the AMIA office in writing on or prior to May 9, 2000. If the alternate is not an AMIA member, he or she will be charged the corresponding additional amount.
Cancellations: If a registrant needs to cancel his or her registration, the AMIA office must receive a request in writing. If the request is received by May 9, 2000, AMIA will refund the meeting registration fee minus a $50 processing charge. If the written request is received between May 10 and May 16, AMIA will refund half of the registration fee. Refund requests received after May 16 will be honored only for a documented medical emergency. Refunds will be processed within four weeks after the meeting. For registrants who cannot attend the meeting and who did not cancel or transfer their registration, AMIA cannot apply fees to future AMIA meetings.
On-Site Registration: Registration is available on-site during the conference at the following hours: | |||||||||||||||
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American Medical Informatics Association 4915 St. Elmo Avenue, Suite 401, Bethesda, MD 20814 Telephone: 301-657-1291 Fax: 301-657-1296 E-mail: mail@amia.org | |||||||||||||||